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Property of the 

Lancaster City and County 
Medical Society 














&C. &C &C. 






Entered according to Act of Congress, in the year 1850, by 


in the Clerk's Office of the District Court of the Eastern District of Pennsylvania, 




The communications of Drs. Joynes, Bond, C. P. Johnson, and Holmes, shall 
appear in our next. 

We have on our table a number of publications which we had designed to 
notice in this No., but have been compelled to defer doing so until our next, 
when they shall receive due attention. 

The following works have been received : — 

Recherches sur la Paralysie Generale progressive, pour servir a Fhistoire de 
cette Maladie. Par Le Docteur L. Lunier. Paris, 1849. 

A Treatise on the Inflammations of the Eye-ball: including the idiopathic, 
scrofulous, rheumatic, arthritic, syphilitic, gonorrhoeal, post-febrile, sympa- 
thetic, phlebitic, and neuralgic species or varieties ; together with Circumscribed 
Inflammation of the cornea, chamber of aqueous humour, crystalline lens, cho- 
roid membranes and retina, and inflammation of the eye from injury. By Ar- 
thur Jacob, M. D., F. R. C. S., &c. Dublin, 1849. (From the Author.) 

On Diseases of Menstruation and Ovarian Inflammation, in connexion with 
Sterility, Pelvic Tumours, and Affections of the Womb. By Edward John 
Tilt, M. D. London, 1850. (From the Author.) 

A Treatise on the Pathology, Diagnosis, and Treatment of Neuroma. By 
Robert W. Smith, M. D., T. C. D., M. R. I. A., &c. &c. Dublin, Hodges & 
Smith, 1849. (From the Author.) 

Essays on the Puerperal Fever, and other Diseases peculiar to Women. Se- 
lected from the writings of British Authors previous to the close of the eighteenth 
century. Edited by Flfetwood Churchill, M. D., M. R. I. A., &c. &c. Phila- 
delphia, Lea & Blanchard, 1850. (From the Publishers.) 

A Practical Treatise on Inflammation of the Uterus and its Appendages, and 
on Ulceration and Induration of the Neck of the Uterus. By James Henry 
Bennett, M. D., M. R. C. P., &o. &c. Second American, from the second 
London edition. Philadelphia, Lea & Blanchard, 1850. (From the Publishers.) 

Medical Jurisprudence. By Alfred Taylor, F. R. S. Second American 
from the third London edition. With Notes and Additions by R. Eglesfeld 
Griffith, M. D., &c. Philadelphia, Lea & Blanchard, 1850. 

A Systematic Treatise, Historical, Etiological, and Practical, on the Principal 
Diseases of the Interior Valley of North America, as they appear in the Cau- 
casian, African, Indian, and Esquimaux Varieties of its Population. By 
Daniel Drake, M. D. Cincinnati, 1850. (From the Author.) 

The American Medical Formulary : based upon the United States and British 
Pharmacopoeias. Including, also, numerous standard Formulae derived from 
American and European authorities ; together with the Medical Properties and 
Uses of Medicines : Poisons, their Antidotes, Tests, &c, designed for the Medi- 
cal and Pharmaceutical Student. By John J. Reese, M. D., Lecturer on Mat. 
Med. and Therap. in Philadelphia Medical Institute. Philadelphia, Lindsay & 
Blakiston, 1850. (From the Publishers.) 

The Druggist's General Receipt Book : containing numerous Recipes for 
Patent and Proprietary Medicines, Druggists' Nostrums, &c. ; Factitious Mine- 
ral Waters, and Powders for preparing them ; with a Veterinary Formulary, 
and Tables of Veterinary Materia Medica ; also, Recipes for Perfumery and 
Cosmetics, Beverages, Dietetic Articles and Condiments, Trade Chemicals, Mis- 
cellaneous Compounds used in the Arts, Domestic Economy, &c, with useful 
Tables and Memoranda. By Henry Beasley. Philadelphia, Lindsay & Blakis- 
ton, 1850. (From the Publishers.) 

The Life and Correspondence of Andrew Combe, M. D., F. R. C. P. Ed., &c. 
&c. By George Combe. Philadelphia, A. Hart, 1850. (From the Publisher.) 

Transactions of the Medical Society of the State of New York, during its 
Annual Session, held at Albany, February 5th, 1850. Albany, 1850. (From 
Dr. Beck.) 


The New Jersey Medical Keporter, and Transactions of the New Jersey 
Medical Society. Edited by Joseph Parrish, M. D. April, 1850. 

Journal of the Proceedings of the Michigan Medical Association for the years 

1849, 1850, Vol. I. Jackson, 1850. 

Transactions of the Medical and Physical Society of Bombay, Nos. VIII. and 
IX. Bombay, 1846-7-8. (From the Society.) 

Account of an Operation for the Removal of an Ovarian Tumour. By Alden 
March, M. D. (From the Author.) 

Remarks on the Comparative Value of the different Anaesthetic Agents. By 
Geo. Hayward, M. D. Boston, 1850. (From the Author.) 

Southern Medical Reports ; consisting of General and Special Reports on the 
Medical "Topography, Meteorology, and Prevalent Diseases in the following 
States — Louisiana, Alabama, Mississippi, North Carolina, South Carolina, 
Georgia, Florida, Arkansas, Tennessee, Texas. To be published annually. 
Edited by E. D. Fenner, M. D., of New Orleans. New Orleans and New York, 

1850. (From the Author.) 

Eleventh Annual Report of the Directors and Superintendents of the Ohio 
Lunatic Asylum to the forty-eighth General Assembly of the State of Ohio, for 
the year 1849. Columbus, 1850. (From Dr. Awl.) 

The Annual Report of the Board of Health of the city of New Orleans for 

1849. New Orleans, 1850. (From Dr. E. H. Barton.) 

Annual Report of the Directors and Warden of the Ohio Penitentiary to the 
forty-eighth General Assembly of the State of Ohio for the year 1849. Colum- 
bus, 1850. (From Wm. Trevitt, M. D., Physician to the Institution.) 

Third Annual Report of the Regents of the University of the Condition of the 
State Cabinet of Natural History and the Historical and Antiquarian Collection 
annexed thereto. Made to the Senate, January 11, 1850. Albany, 1850. 
(From the Regents.) 

Annual Report of the Physician of the Marine Hospital, made to the Legis- 
lature March 26th, 1850. Albany, 1850. (From Dr. F. C. Stewart.) 

The Twenty-first Annual Report of the Inspectors of the Eastern State Peni- 
tentiary of Pennsylvania. Philadelphia, 1850. (From Dr. Given.) 

Report of the Select Committee of the Legislature of 1849 on the Publication 
of the Natural History of the State of New York. Made to the Legislature, 
January 2, 1850. Albany, 1850. (From Dr. T. R. Beck.) _ 

Eighteenth Annual Report of the Trustees of the Perkins Institution and 
Massachusetts Asylum for the Blind to the Corporation. Cambridge, 1850. 
(From Dr. E. Jarvis.) 

Physic and the Physicians. The Annual Address delivered before the Ala- 
bama State Medical Association, at the Capitol, December 10th, 1849. By 
"VVm. O. Baldwin, M. D. Printed by order of the Association. Montgomery, 

1850. (From the Author.) 

Anniversary Oration before the New York Academy of Medicine, delivered 
in the Chapel of the University of the City of New York, November 11th, 1849. 
By Alfred C. Post, M. D. Published by order of the Academy. New York, 

A Valedictory Address to the Graduates of the University of Pennsylvania, 
delivered April 6th, 1850. By Hugh L. Hodge, M. D., Professor of Obstetrics, 
&c. Philadelphia, 1850. 

Annual Address delivered before the New York State Medical Society, and 
Members of the Legislature, at the Capitol, February 6, 1850. By Alex. H. 
Stevens, M. D., President of the Society. (From the Author.) 

Medicine a Science and an Art. A Lecture introductory to the Course in the 
Medical Institution of Geneva College. By C. B. Coventry, M. D., Professor 
of Obstetrics, &c. Published by the Class. Geneva, 1850. 

Valedictory Address to the Graduating Class of the Medical Department of 
Transylvania University, at the Commencement, March 1, 1850. By Wm. M. 
Boling, M. D., Prof, of Obstetrics, 1850. 

Address delivered before the Class of the Baltimore College of Dental Sur- 
gery at the conclusion of the last lecture of the Course for the Session 1849-50. 


By Chap. A. A. Harris, M. D., Prof, of Principles and Practice of Dental Sur- 
gery. Baltimore, 1850. 

An Address delivered before the Suffolk District Medical Society, at its first 
Anniversary Meeting, Boston, April 27, 1850. By John Jeffries, M. D., Pre- 
sident of the Society. Boston, 1850. (From the Author.) 

Opening Address delivered before the Society of the Alumni of the Baltimore 
College of Dental Surgery, at the second annual meeting, March 26th, 1850 
By E. Townsend, D. D. Published by request of the Society. Baltimore, 
1850. (From the Author.) 

Annual Announcement of the Medical Department of the St. Louis Univer- 
sity — session 1850-51. St. Louis, 1850. 

Catalogue of the Trustees, Officers, and Students of the University of Penn- 
sylvania, session 1849-50. Philadelphia, 1850. 

Primary Announcement of the Course of Lectures in the Medical Department 
in the University of Michigan, session 1850-51. Ann Arbour, Michigan, 

Report of the Committee of Internal Health on the Asiatic Cholera, together 
with a Report of the City Physician of the Cholera Hospital. Boston, 1849. 
(From Dr. H. G. Clark.) 

Ship Fever, so called ; its History, Nature, and best Treatment. The Fish 
Fund Prize Dissertation for 1849. By H. G. Clark, M. D., &c. Boston, 1850. 
(From the Author.) 

An Historical Sketch of the State of Medicine in the American Colonies from 
their settlement to the period of the Revolution. By John B. Beck, M.D., 
Prof, of Materia Medica and Medical Jurisprudence in the College of Physi- 
cians and Surgeons of the city of New York. Second edition. Albany, 1850. 
(From the Author.) 

Letter of Gail Borden, Jr., to Dr. Ashbel Smith, setting forth an important 
invention in the preparation of a new article of food, termed meal-biscuit ; and 
the reply of Dr. Smith thereto: being a letter addressed to the American Asso- 
ciation for the Promotion of Science, at their semi-annual meeting, to be held 
at Charleston, in March next. Galveston, 1850. (From Dr. Smith.) 

An Essay on the Opium Trade, including a Sketch of its History, Extent, 
Effects, &c, as carried on in India and China. By Nathan Allen, M. D. 
Boston, 1850. (From the Author.) 

The following journals have been received in exchange: — 

Revue Medicale Francaise et etrangerc Par J. B. Cayol. May, June, 
July, Aug., Sept., Oct., Nov., Dec, 1849. 

Annales Medico-Psychologiques. Journal destine a recueillir tons les docu- 
ments relatifs a Y alienation mentale, aux nevroses et a la medecine legale des 
alienes. Par MM. Les Docteurs Baillarger et Cerise. July, Oct., 1849. 

Gazette Medicale de Paris. Aug., Sept., Oct., Nov., Dec, 1849, Jan., 1850. 

Journal des Connaissances Medico-Chirurgicales. Publie par Le Docteur A. 
Martin Lauzer. Aug., Sept., Oct., Nov., Dec, 1849, Jan., 1850. 

Journal des Connaissances M6dicales Pratiques et de Pharmacologic Aug., 
Sept., 1849. 

The London Medical Gazette. March, April, May, 1850. 

The British and Foreign Medico-Chirurgical Review. April, 1850. 

Monthly Journal of Medical Science, conducted by Dr. S. R. Christison, J. Y. 
Simpson, J. H. Bennett, D. Maclagan, and Wm. Robertson, and J. Syme and 
J. Goodsir, Esqrs. April, May, June, 1850. 

London Journal of Medicine, a Monthly Record of the Medical Sciences. 
April, May, June, 1850. 

The Edinburgh Medical and Surgical Journal, April, 1850. 

The Journal of Psychological Medicine and Mental Pathology. Edited by 
Forbes Winslow, M. D. April, 1850. 

Provincial Medical and Surgical Journal. Edited by W. H. Ranking, M. 
D., and J. H. Walsh, Esq. March, April, May, 1850. 

Medical Times. March, April, May, 1850. 

Dublin Medical Press. March, April, May, 1850. 

The Dublin Quarterly Journal of Medical Science. May, 1850. 



British American Journal of Medical and Physical Science. Edited by A. 
Hall, M. D. April, May, 1850. 

The North-Western Medical and Surgical Journal. Edited by John Evans, 
M. D., and Edwin G. Meek, M. D., March, May, 1850. 

Southern Medical and Surgical Journal. Edited by J. P. Garvin, M. D. 
April, May, June, 1850. 

The Medical Examiner. Edited by F. G. Smith, M. D. April, May, June, 
1850. P * 

Buffalo Medical Journal and Monthly Review of Med. and Surg. Science, &c. 
Edited by Austin Flint, M. D. April, May, June, 1850. 

The Western Journal of Medicine and Surgery. Edited by L. P. Yandell, 
M. D., and T. S. Bell, M. D. April, May, 1850. 

The American Journal of Pharmacy, published by authority of the Philadel- 
phia College of Pharmacy. Edited by Jos. Carson, M. D., and Wm. Proctor, 
Jr., Profs, in Philad. Coll. of Pharmacy. April, 1850. 

The New Orleans Medical and Surgical Journal. Edited by A. Hester, M. 
D. March, May, 1850. 

The Boston Medical and Surgical Journal. Edited by J. V. C. Smith, M. 
D. April, May, June, 1850. 

Northern Lancet and Gazette of Legal Medicine. Edited by Drs. F. J. D. 
Avignon, and H. Nelson. 

The Western Lancet and Hospital Reporter. Edited by L. M. Lawson, M. 
D. April, May, 1850. 

Transylvania Medical Journal. Edited by E. D. Dudley, M. D. April, 

St. Louis Medical and Surgical Journal. Edited by Drs. Linton, Moore, Mc- 
Pheeters and Johnson. March and April, 1850. 

The New York Journal of Medicine and the Collateral Sciences. Edited by 
J. S. Purple, M. D. May, 1850. 

The Ohio Medical and Surgical Journal. Edited by S. Hanbury Smith, M. 
D. May, June, 1850. 

The American Journal of Science and the Arts. Conducted by Profs. B. 
Silliman, and B. Silliman, Jr., and James D. Dana. May, 1850. 

The American Journal of Insanity. Edited by the officers of the New York 
State Lunatic Asylum, Utica. April, 1850. 

The Charleston Medical Journal and Review. Edited by D. J. Cain, M. D., 
and T. P. Porcher, M. D. May, 1850. 

Communications intended for publication, and Books for' Review, should be sent, free 
of expense, directed to Isaac Hays, M. D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above, and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, London ; 
or to John Wiley, or G. P. Putnam, New York; or W. D. Ticknor, Boston; or M. Hector 
Bossange, Lib. quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Lea & Blanchard. 

(Xj 3 The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 







JULY, 1850. 



I. Dr. Harlow's Case of Recovery from the passage of an Iron Bar through 
the Head. By Henry J. Bigelow, M. D., Professor of Surgery in Har- 
vard University. [With a plate.] - - - - - - 13 

II. Remarks on the Relation of the Dumb-Bell Crystals to Uric Acid. By 
Charles Frick, M. D., of Baltimore, Maryland. [With a- wood-cut.] - 23 

III. Extracts from the Records of the Boston Society for Medical Improve- 
ment. By Wm. W. Morland, Secretary. [With a wood-cut.] - -26 

IV. Annual Report of the Committee on Medical Chemistry. By Jno. C. 
Dalton, Jr., M. D. (Read before the Boston Society for Medical Ob- 
servation, June 4th, 1849.) - - - - - - 41 

V. Case of Extra-Uterine Foetation. By Wm. Denny, M. D., of Ellicott's 
Mills, Howard District, Anne Arundel county, Md. - - - 49 

VI. Remarks on Obstetrical Forceps, with an attempt at their improve- 
ment. By Henry Bond, M. D. [With three wood-cuts.] - - 62 

VII. Histological Researches on the Development, Nature, and Function 
of Epithelial Structures. By W. J. Burnett, M. D. (Read before the 
Boston Society for Natural History, Aug. 1, 1849.) - - - 70 

VIII. On Cholera Asphyxia. By James F. Gayley, M. D., of Philadel- 
phia. t - -- - - - - 83 

IX. Notice of certain Peculiar Bodies observed in the Human Subject. 

By Joseph Leidy, M. D. [With five wood-cuts.] - - - - 89 

X. Ligature of Internal Iliac Artery for Aneurism. By Gilman Kimball, 

M. D., of Lowell, Massachusetts. - - - - - - 92 

XL Abstract of a Case of Constitutional Irritation following Vaccination. 
By Charles E. Buckingham, M. D., Physician to the Boston House of 
Industry. - - - - - - - - -96 

XII. A Case of Wound of the left Ventricle of the Heart. — Patient sur- 
vived five days; — with remarks. By John W. H. Trugien, M. D., of 
Portsmouth, Va. - - - - - - - 99 

XIII. Poisoning by the Seeds of Jatropha Curcas. By R. J. Farquharson, 
M. D., Assistant Surgeon U. S. N. Communicated by T. Harris, M. D., 
Chief of the Bureau of Medicine and Surgery, U. S. N. - - 102 



XIV. Results of Fifteen Operations for Lithotomy. By P. C. Spencer, 

M. D., of Petersburg, Virginia. ------ 103 

XV. Displacement of the Heart from Atrophy of the Left Lung. By C. 

J. Clark, M. D., of Jacksonville, Alabama. - 106 


XVI. A Systematic Treatise, Historical, Etiological, and Practical, on 
the Principal Diseases of the Interior Valley of North America, as they 
appear in the Caucasian, African, Indian, and Esquimaux varieties of 
its Population. By Daniel Drake, M. D. Cincinnati, 1850 : 8vo. pp. 
878. 109 


XVII. The Microscopic Anatomy of the Human Body in Health and Dis- 
ease. Illustrated with numerous drawings in colour. By Arthur Hill 
Hassall, M. B., author of a " History of the British Freshwater Algae," 
Fellow of the Linnasan Society, &c. &c. In two volumes, 8vo. : London, 
1849. 121 

XVIII. Surgical Anatomy. By Joseph Maclise, Surgeon. With coloured 
plates. Part II. Philadelphia, Lea & Blanchard, 1850. - - 123 

XIX. Essays on the Puerperal Fever, and other Diseases peculiar to 
Women, selected from the Writings of British Authors previous to the 
close of the Eighteenth Century, by request of the Sydenham Society. 
Edited by Fleetwood Churchill, M. D., M. R. I. A., &c. &c. Philadel- 
phia, Lea & Blanchard, 1850 : 8vo. pp. 464. - - - - 126 

XX. Essay on Syphilitic Sarcocele. By John Hamilton, Surgeon to the 
Richmond Hospital, Dublin: pp. 40, with two coloured lithographs. 
Dublin, 1849. 129 

XXI. Report of the Committee of Internal Health on the Asiatic Cholera, 
together with a Report of the City Physician (Dr. Henry G. Clark) on 
the Cholera Hospital. Boston, 1849 : 8vo. pp. 182. - - - 131 

XXII. The Annual Report of the Board of Health of the City of New 
Orleans, for 1849. 8vo. pp. 16. New Orleans, 1850. - - -136 

XXIII. Nonnula de Morbis Unguium. Auctor Ludovicus Benjamin, 

On some of the Diseases of the Nails. By Lewis Benjamin, of Hamburgh. 
Berlin, 1849 : 12mo. pp. 32. 139 

XXIV. Southern Medical Reports ; consisting of General and Special 
Reports on the Medical Topography, Meteorology, and Prevalent Dis- 
eases in the following States : Louisiana, Alabama, Mississippi, North 
Carolina, South Carolina, Georgia, Florida, Arkansas, Tennessee, Texas. 
To be published annually. Edited by E. D. Fenner, M. D.,.etc. etc., of 
New Orleans. New Orleans and New York : Vol. 1. 1849 : 8vo. pp. 472. 141 

XXV. Ship Fever, so called ; its History, Nature, and Best Treatment. 
The Fiske Fund Prize Dissertation, for 1849. By Henry Grafton Clark, 
M. D., Member of the Boston Society for Medical Improvement. " Per 
Ardua." Printed by order of the Rhode Island Medical Society. 8vo. 

pp. 48. Boston, 1850. 144 

XXVI. Dietetical and Medical Hydrology. A Treatise on Baths ; in- 
cluding Cold, Sea, Warm, Hot, Vapour, Gas, and Mud Baths: also, on 
the Watery Regimen, Hydropathy, and Pulmonary Inhalation ; with a 
description of Bathing in Ancient and Modern times. By John Bell, 
M. D., etc. etc. Philadelphia, Barrington & Haswell, 1850 : 12mo. pp. 
658. - - - - - 149 



XXVII. The History, Diagnosis, and Treatment of Edematous Laryngitis. 
By Elisha Bartlett, M. D., Professor of the Theory and Practice of 
Medicine in the University of Louisville. Louisville, 1850 : 8vo. pp. 34. 150 

XXVIII. The Life and Correspondence of Andrew Combe, M. D., &c. &c. 
By George Combe. Res non verba quseso. Philadelphia, A. Hart, late 
Carey & Hart, 1850 : 12mo. pp. 428. - - - - 150 

XXIX. Remarks on the Comparative Value of the different Anaesthetic 
Agents. By George Hayward, M. D., one of the Surgeons to the Massa- 
chusetts General Hospital. Boston, 1850: 8vo. pp. 11. - 151 

XXX. Physic and Physicians. The Annual Address delivered before the 
Alabama State Medical Association. By William O. Baldwin, M. D. 
Montgomery, 1850 : 8vo. pp. 43. - - - - - - 154 

XXXI. Production of Vital Force. By Edward Jarvis, M. D. 8vo. pp. 
77: Boston,1849. - 156 

XXXII. Opening Address delivered before the Society of the Alumni of 
the Baltimore College of Dental Surgery, at the Second Annual Meet- 
ing, March 26th, 1850. By E. Townsend, D. D. S. - - - 159 





Anatomy and Physiology. 

1. On the Pelvico-Prostatic Liga- 
ment, or the Apparatus by 
which the Bladder, Prostate, and 
Urethra are attached to the out- 
let of the Pelvis. By Retzius. - 161 

2. On the Existence of two new 
kinds of Anatomical Elements 
in the Medullary Canals of 
Bones. By M. Ch. Robin. - 163 

3. Researches on the Physiology 
of the Medulla Oblongata. By 


M. Brown-Sequard. - - - 163 

4. On the Emission of Urine, as 
observed in an individual suffer- 
ing from Ectopia of the Bladder. 

By Dr. Parmeggiani. - - 164 

5. Experimental researches on the 
Contractility of the Spleen. - 164 

6. On the Means of measuring de- 
grees of Anaesthesia and Hy- 
peresthesia. By M. Brown-Se- 
quard. 164 

Materia Medica and Pharmacy. 

7. On the Cod-liver Oils of Com- 
merce — and on the Beneficial 
Effects of the cheaper Fish Oils. 

By Dr. Bagot. - - _ - - 165 

8. Almond Oil as a substitute for 
Cod-Liver Oil. By Dr. P. M. 
Duncan and Mr. R. S. Nunn. - 166 

9. Citrate of Iron and Magnesia. 
By M. Van der Corput. • 

10. Alkali obtained from the Khaya 
Senegalensis (Swietenia Sene- 
galensis) a cheap substitute for 
Quinine. By M. Caventou. 

11. Physiological Effects of Oil of 

- 167 





Turpentine. By Dr. Thomas 

Smith. 168 

12. On the Relative Potency of 
Chloroform and Ether, and on 


some Dangerous Effects of Chlo- 
roform. By John Snow, M. D. 168 
13. Adulteration of Muriate of 
Morphia. By Morson. . - 170 

Medical Pathology, Therapeutics, and Practical Medicine. 

14. On Typhoid and Typhus Fe- 
vers. An attempt to Determine . 
the Question of their Identity, 
or Non-Identity, by an Analysis 
of the Symptoms, and of the 
Appearances found after Death, 
in Sixty-six Fatal Cases of Con- 
tinued Fever, observed at the 
London Fever Hospital, from 
January, 1847, to February, 

^1849. By W. Jenner, M. D. - 171 

15. On the Treatment of Ague by 
a Single Dose of Quinine. By 
Dr. C. Pfeufer. - - - - 178 

16. Treatment of Phthisis. By 
Dr. James Trumbull. - - 178 

17. Cicatrices in the Lungs. Dr. 

W. T. Gairdner. - - - 182 

18. Clinical Remarks on Gangrene 
of the Lungs. By Wm. Stokes, 

M. D. 182 

19. Case of Communication be- 
tween the Rectum, Bladder, and 
left Ovary ; Calculus in the left 
Kidney ; great Enlargement of 
the Liver, with Lateral Curva- 
ture of the Spine. By T. P. 
Heslop, M. D. - - - - 183 

20. Granular Corpuscles in the 
Encephalon and Spinal Cord of 
Hemiplegic Patients. By Dr. 

Ludwig Tuerck. - 185 

21. Cryptogamic Vegetations in 
the interior of the Hair in Fa- 
vus. By Dr. C. Wedl. - - 186 

22. On Anemia from Diminished 
Proportion of Albumen in the 
Blood, and on the Dropsies 
which it occasions. By MM. 
Becquerel and Rodier. - - 187 

23. On Chlorotic Tinnitus. By Dr. 
Froriep. 188 

24. Chemical Researches on the 
Nature and Cause of Cholera. 

By Dr. R. D. Thomson, M. D. - 189 

25. Gooseberry Disease. By Dr. 
Jahn. 190 

26. Cases of Abscess behind the 
Pharynx. By Christopher Fle- 
ming, M. D. - - - - 191 

27. On a Peculiar Disease of the 
Nasal Fossa. By Dr. John 
Gairdner. 194 

28. Erythema Nodosum. By Dr. 
Begbie. - - - - - 195 

29. Therapeutical Effects of Tur- 
pentine. By Thomas Smith, 

M. D. - 196 

30. Remarks on Yermifuges. By 
Dr. Cazin. 200 

31. Treatment of Chorea. By M. 
Faivre D'Esnans. - - - 202 

Surgical Pathology and Therapeutics, and Operative Surgery. 

32. Diseases of the Membrana 
Tympani. By Mr. Toynbee. - 202 

33. Caries of the Head of the Fe- 
mur. By Mr. Henry Smith. - 204 

34. Case of Perineal Abscess in 
which the pus made its way into 

the scrotum. By Mr. Rumley. 204 

35. A Remarkable Case of Re- 
lapses in Cancer. - 205 

36. On Femoral Hernia. By M. 
Malgaigne. - 206 

37. Cases of Vascular Tumour of 
the Urethra, with Remarks. By 

H. B. Norman. - - - - 209 

38. Rupture of the Urinary Blad- 
der. By Mr. Solly and Mr. Sta- 
pleton. - - - - - 209 

39. Case of Gunshot Wound, and 
subsequent Extraction of a Bul- 
let from the Bladder. By E. M. 
Macpherson. - 214 

40. On Dressing "Wounds and Ul- 
cers with Charcoal. By Dr. 
Newmann. - 215 

41. On Disjunction of the Lower 
Epiphysis of the Humerus. By 
Wm. Smith, M. D. - - - 216 

42. Perpendicular fall from a 
height of 192 feet — Fracture of 
the thigh and patella, with se- 
vere concussion of the thoracic 
viscera — perfect recovery. By 
Dr. Knox. 219 



43. Ligature of the Subclavian Ar- 
tery for Aneurism. By James 
Syme, Esq. 

44. Paracentesis Thoracis. ByDr 
George F. Easton. 

45. Successful Amputation at Hip 


- 222 

- 223 

Joint. By R. B. Wigstrom, Esq. 229 
46. On Lithotomy and Lithotrity : 
Being an Account of the Expe- 
rience of MM. Pamard, Sen. and 
Jun., from 1792 to 1849. By 
M. Pamard. - - - - 229 


47. Malignant Tumour in the Or- 
bit successfully extirpated. By 
Thomas Paget, Esq. - - - 237 

48. Melanosis of the Eye. By 

John Windsor, Esq. - - - 237 
49. Coincidence of Albuminuria 
and Amaurosis. By Dr. Lan- 
douzy. 240 


50. New form of Obstruction in 
Head Presentations, from Poste- 
rior Displacement of the Arm. 

By Professor Simpson. - - 241 

51. Case of Spontaneous Expul- 
sion of the Child. By Dr. Robert 
Dyce. - - - - - 243 

52. Lingering Labour from a Stric- 
ture of the Uterine Parietes 
around the Child's Neck. By 
Dr. Skae. 244 

53. Rare Obstetric Cases. By C. 

D. Purdon, M. B. - - - 245 

54. Operation for Calculus Vesicae 
during Labour. By M. Monod. 246 

55. Remarkable Case of Retention 
of Urine after Delivery. By M. 
Malgaigne. -'.-.-- 246 

56. Cases of Tetanus coming on 
after Abortion. By Dr. A. Wood. 247 

57. Gangrene of the Vulva. By 

M. Monat. - - - - - 248 
'58. Puerperal Mania. By Dr. F. 

Churchill. 248 

59. On the Administration of Chlo- 
roform in Midwifery, and as a 
Sedative of Uterine Pain gene- 

rally. By J. Henry Bennet, 
M. D. 249 

60. Insanity from the Use of Chlo- 
roform. By Dr. Webster. - 250 

61. A Series of Cases Illustrating 
the Contagious Nature of Ery- 
sipelas and of Puerperal Fever, 
and their Intimate Pathological 
Connection. By Dr. Hill. - 250 

62. Inflammation of the Mammae. 

By Mr. T. W. Nunn. - - 252 

63. Diagnosis between Real and 
Apparent Death in Newly-born 
Children. By M. Van Hengel. 254 

64. Discussion in the French 
Academy of Medicine upon En- 
gorgements of the Uterus. By 

M. Hervez de Chegoin. - - 255 

65. On the alleged frequency of 
Ulceration of the Os and Cervix 
Uteri — Speculum Practice. By 
Dr. Tyler Smith. - - - 258 

66. Condition of the Ovaries and 
Uterus, observed in a young wo- 
man assassinated shortly after 
Menstruation. By Dr. Janzer. 262 


Original Communications. 

Microscopic Examination of the 
Discharges from the Bowels in 
Cholera. By Dr. R. S. Holmes. 263 

Compound Fracture of the Skull 
with Laceration of the Meninges 
of the Brain successfully treated 
by the application of the tre- 
phine eleven days after the in- 
jury. By J. M. Hurt, M. D. - 263 

Cases of Intestinal Disease. By 
William Gries, M. D. - - 266 

Solid Ovarian Tumour, extending 
from Pubis to right Hypochon- 
drium. — Cured by Incision fol- 
lowed by Suppuration. . By Da- 
vid Prince, M. D. - - 267 

Removal of three inches of Gum- 
Elastic Catheter with Heurte- 
loup's Instrument. By J. H. 
Dillson. ... = - 268 

Obituary Notice. - - - - 268 



Domestic Summary. 

Malignant Tumour of eight or ten 
years' standing, cured after two 
years by a strict diet of bread 
and milk. By Dr. H. J. Bow- 
ditch. m 269 

Successful Ligature of the Femoral 
Artery for Wound of the Ante- 
rior Tibial.— By Dr. E. P. Ben- 
nett. 272 

Fibrous Tumour of the left Ova- 
rium successfully 'removed by 
the large Abdominal Section. 

By Dr. W. H. Van Buren. 

Tubal Pregnancy with Rupture of 
the Fallopian Tube. By Dr. W. 
C. Horlbeck. - 

Diphtheritic Inflammation of the 
Pharynx as it prevailed epidemi- 
cally, during the years 1847, '48, 
and '49, in Morgan, Monroe, and 
Guernsey counties, Ohio. By 
David Welsh, M. D. - 

University of Pennsylvania. 

List of Graduates. - 








FOR JULY 1850. 

Art. I. — Dr. Harlow' 's Case of Recovery from the passage of an Iron Bar 
through the Head. By Henry J. Bigelow, M. D., Professor of Surgery 
in Harvard University. (With a plate.) 

The following case, perhaps unparalleled in the annals of surgery, and of 
which some interesting details have already been published, occurred in the 
practice of Dr. J. M. Harlow, of Cavendish, Vermont. Having received a 
verbal account of the accident, a few days after its occurrence, from a medical 
gentleman who had examined the patient, I thus became incidentally inte- 
rested in it; and having since had an opportunity, through the politeness of 
Dr. Harlow, of observing the patient, who remained in Boston a number of 
weeks under my charge, I have been able to satisfy myself as well of the 
occurrence and extent of the injury as of the manner of its infliction. I am 
also indebted to the same gentleman for procuring at my request the testi- 
mony of a number of persons who were cognizant of the accident or its sequel. 

Those who are skeptical in admitting the co-existence of a lesion so grave, 
with an inconsiderable disturbance of function, will be interested in further 
details connected with the case ; while it is due to science that a more com- 
plete record should be made of the history of so remarkable an injury. 

The accident occurred upon the line of the Rutland and Burlington Rail- 
road, on the 13th of September, 1848. The subject of it, Phineas P. Gage, 
is of middle stature, twenty-five years of age, shrewd and intelligent. Accord- 
ing to his own statement, he was charging with powder a hole drilled in a 
rock, for the purpose of blasting. It appears that it is customary in filling 
the hole to cover the powder with sand. In this case, the charge having been 
adjusted, Mr. Gage directed his assistant to pour in the sand ; and at the 
interval of a few seconds, his head being averted, and supposing the sand to 
have been properly placed, he dropped the head of the iron as usual upon the 
No. XXXIX.— July, 1850. 2 

14 Bigelow's Case of Injury of Head. [July 

charge, to consolidate or " tamp it in." The assistant had failed to obey the 
order, and the iron striking fire upon the rock, the uncovered powder was 
ignited and the explosion took place. Mr. Gage was at this time standing 
above the hole, leaning forward, with his face slightly averted ; and the bar 
of iron was projected directly upwards in a line of its axis, passing completely 
through his head and high into the air. The wound thus received, and which 
is more fully described in the sequel, was oblique, traversing the cranium 
in a straight line from the angle of the lower jaw on one side to the centre 
of the frontal bone above, near the sagittal suture, where the missile emerged; 
and the iron thus forcibly thrown into the air was picked up at a distance of 
some rods from the patient, smeared with brains and blood. 

From this extraordinary lesion, the patient has quite recovered in his facul- 
ties of body and mind, with the loss only of the sight of the injured eye. 

The iron which thus traversed the skull weighs thirteen and a quarter 
pounds. It is three feet seven inches in length, and one and a quarter inches 
in diameter. The end which entered first is pointed ; the taper being seven 
inches long, and the diameter of the point one quarter of an inch ; circum- 
stances to which the patient perhaps owes his life. The iron is unlike any 
other, and was made by a neighbouring blacksmith to please the fancy of the 

Dr. Harlow, in the graphic account above alluded to, states that " immedi- 
ately after tl;e explosion the patient was thrown upon his back, and gave a few 
convulsive motions of the extremities, but spoke in a few minutes. His men 
(with whom he was a great favourite) took him in their arms and carried him 
to the road, only a few rods distant, and sat him into an ox cart, in which he 
rode, sitting erect, full three quarters of a mile, to the hotel of Mr. Joseph 
Adams, in this village. He got out of the cart himself, and with a little 
assistance walked up a long flight of stairs, into the hall, where he was 

Mr. Joseph Adams, here spoken of, has furnished the following interesting 
statement :— 

This is to- certify that P. P. Gage had boarded in my house for several 
weeks previous to his being injured upon the railroad, and that I saw him and 
conversed with him soon after the accident, and am of opinion that he was per- 
fectly conscious of what was passing around him. He rode to the house, three- 
quarters of a mile, sitting in a cart, and walked from the cart into the piazza, 
and thence up stairs, with but little assistance. I noticed the state of the left 
eye, and know, from experiment, that he could see with it for several days, 
though not distinctly. In regard to the elevated appearance of the wound, and 
the introduction of the finger into it, I can fully confirm the certificate of my 
nephew, Washington Adams, and others, and would add that I repeatedly saw 
him eject matter from the mouth similar in appearance to that discharged from 
the head. The morning subsequent to the accident I went in quest of the bar, 
and found it at a smith's shop, near the pit in which he was engaged. 

The men in his pit asserted that " they found the iron, covered with blood 

1850.] Bigelow's Case of Injury of Head. 15 

and brains," several rods behind where Mr. Gage stood, and that they washed 
it in the brook, and returned it with the other tools ; which representation was 
fully corroborated by the greasy feel and look of the iron, and the fragments of 
brain which I saw upon the rock where it fell. 


Cavendish, Dec. 14, 1849. Justice of the Peace. 

The Rev. Joseph Freeman, whose letter follows, informed himself of the 
circumstances soon after the accident. 

Cavendish, Dec. 5, 1849. 

Dear Sir — I was at home on the day Mr. Gage was hurt ; and seeing an 
Irishman ride rapidly up to your door, I stepped over to ascertain the cause, 
and then went immediately to meet those who I was informed were bringing 
him to our village. 

I found him in a cart, sitting up without aid, with his back against the fore- 
board. When we reached his quarters, he rose to his feet without aid, and 
walked quick, though with an unsteady step, to the hind end of the cart, when 
two of his men came forward and aided him out, and walked with him, sup- 
porting him to the house. 

I then asked his men how he came to be hurt? The reply was, "The blast 
went off when he was tamping it, and the tamping-iron passed through his 
head." I said, " That is impossible." 

Soon after this, I went to the place where the accident happened. I found 
upon the rocks, where I supposed he had fallen, a small quantity of brains. 
There being no person at this place, I passed on to a blacksmith's shop a few 
rods beyond, in and about which a number of Irishmen were collected. As I 
came up to them, they pointed me to the iron, which has since attracted so 
much attention, standing outside the shop-door. They said they found it 
covered with brains and dirt, and had washed it in the brook. The appearance 
of the iron corresponded with this story. It had a greasy appearance, and was 
so to the touch. 

After hearing their statement, as there was no assignable motive for misre- 
presentation, and finding the appearance of the iron to agree with it, I was 
compelled to believe, though the result of your examination of the wound was 
not then known to me. 

I think of nothing further relating to this affair which cannot be more 
minutely stated by others. 

Very respectfully, yours, 


Dr. J. M. Harlow. 

Dr. Williams first saw the patient, and makes the following statement in 
relation to the circumstances : — 

Northfield, Vermont, Dec. 4, 1849. ' 

Dr. Bigelow: Dear Sir — Dr. Harlow having requested me to transmit to you 

a description of the appearance of Mr. Gage at the time I first saw him after 

the accident, which happened to him in September, 1848, I now hasten to do 

so with pleasure. 

Dr. Harlow being absent at the time of the accident, I was sent for, and was 

16 Bigelow's Case of Injury of Head. [July 

the first physician who saw Mr. G., some twenty-five or thirty* minutes after 
he received the injury ; he at that time was sitting in a chair upon the piazza 
of Mr. Adams's hotel, in Cavendish. When I drove up, he said, " Doctor, here 
is business enough for you/ 7 I first noticed the wound upon the head before 
I alighted from my carriage, the pulsations of the brain being very distinct ; 
there was also an appearance which, before I examined the head, I could not 
account for : the top of the head appeared somewhat like an inverted funnel ; 
this was owing, I discovered, to the bone being fractured about the opening for 
a distance of about two inches in every direction. I ought to have mentioned 
above that the opening through the skull and integuments was not far from 
one and a half inch in diameter ; the edges of this opening were everted, and 
the whole wound appeared as if some wedge-shaped body had passed from 
below upward. Mr. Gage, during the time I was examining this wound, was 
relating the manner in which he was injured to the bystanders ; he talked so 
rationally and was so willing to answer questions, that I directed my inquiries 
to him in preference to the men who were with him at the time of the accident, 
and who were standing about at this time. Mr. G. then related to me some of 
the circumstances, as he has since done ; and I can safely say that neither at 
that time nor on any subsequent occasion, save once, did I consider him to be 
other than perfectly rational. The one time to which I allude was about a 
fortnight after the accident, and then he persisted in calling me John Kirwin ; 
yet he answered all my questions correctly. 

I did not believe Mr. Gage's statement at that time, but thought he was 
deceived ; I asked him where the bar entered, and he pointed to the wound on 
his cheek, which I had not before discovered ; this was a slit running from the 
angle of the jaw forward about one and a half inch; it was very much 
stretched laterally, and was discoloured by powder and iron rust, or at least 
appeared so. Mr. Gage persisted in saying that the bar went through his 
head : an Irishman standing by said, " Sure it was so, sir, for the bar is lying 
in the road below, all blood and brains." The man also said he would have 
brought it up with him, but he thought there would be an inquest, and it would 
not do. 

About this time, Mr. G. got up and vomited a large quantity of blood, together 
with some of his food ; the effort of vomiting pressed out about half a teacupful 
of the brain, which fell upon the floor, together with the blood, which was 
forced out at the same time. The left eye appeared more dull and glassy than 
the right. Mr. G. said he could merely distinguish light with it. 

Soon after Dr. Harlow arrived, Mr. Gage walked up stairs, with little or no 
assistance, and laid down upon a bed, when Dr. II. made a thorough exami- 
nation of the wounds, passing the whole length of his forefinger into the supe- 
rior opening without difficulty ; and my impression is that he did the same 
with the inferior one, but of that I am not absolutely certain : after this we 
proceeded to dress the wounds in the manner described by Dr. 11. in the Jour- 
nal. During the time occupied in dressing, Mr. G. vomited two or three times 
fully as freely as before. All of this time Mr. G. was perfectly conscious, 
answering all questions, and calling his friends by name as they came into the 

I did not see the bar that night, but saw it the next day after it was washed. 
Hoping you will excuse this hasty sketch, I remain yours, &c. 


1850.] Bigelow's Case of Injury of Head. 17 

Dr. Harlow's account of his first visit to the patient, and of the subsequent 
symptoms, is here appended. 

" Being absent, I did not arrive at the scene of the accident until near 6 
o'clock, P. M. You will excuse me for remarking here that the picture 
presented was, to one unaccustomed to military surgery, truly terrific ; but 
the patient bore his sufferings with the most heroic firmness. He recognized 
me at once, and said he hoped he was not much hurt. He seemed to be 
perfectly conscious, but was getting exhausted from the hemorrhage, which 
was very profuse both externally and internally, the blood finding its way into 
the stomach, which rejected it as often as every fifteen or twenty minutes. 
Pulse 60, and regular. His person and the bed on which he was laid were 
literally one gore of blood. Assisted by my friend, Dr. Williams, of Proctors- 
ville, who was first called to the patient, we proceeded to dress the wounds. 
Prom their appearance, the fragments of bone being uplifted and the brain 
protruding, it was evident that the fracture was occasioned by some force 
acting from below upward. The scalp was shaven, the coagula removed, 
together with three small triangular pieces of the cranium, and in searching 
to ascertain if there were other foreign bodies there, I passed in the index 
finger its whole length, without the least resistance, in the direction of the 
wound in the cheek, which received the other finger in like manner. A portion 
of the anterior superior angle of each parietal bone, and a semicircular piece 
of the frontal bone, were fractured, leaving a circular opening of about three 
and a half inches in diameter. This examination, and the appearance of the 
iron which was found some rods distant, smeared with brain, together with 
the testimony of the workmen, and of the patient himself, who was still suffi- 
ciently conscious to say that ' the iron struck his head and passed through,' 
was considered at the time sufficiently conclusive to show not only the nature 
of the accident, but the manner in which it occurred. 

"I have been asked why I did not pass a probe through the entire extent 
of the wound at the time. I think no surgeon of discretion would have up- 
held me in the trial of such a foolhardy experiment, in the risk of disturbing 
lacerated vessels, from which the hemorrhage was near being staunched, and 
thereby rupturing the attenuated thread, by which the sufferer still held to 
life. You will excuse me for being thus particular, inasmuch as I am aware 
that the nature of the injury has been seriously questioned by many medical 
men for whom I entertain a very high respect. 

" The spiculas of bone having been taken away, a portion of the brain, 
which hung by a pedicle, was removed, the larger pieces of bone replaced, 
the lacerated scalp was brought together as nearly as possible, and retained 
by adhesive straps, excepting at the posterior angle, and over this a simple 
dressing — compress, nightcap and roller. The wound in the face was left 
patulous, covered only by a simple dressing. The hands and forearms were 
both deeply burned nearly to the elbows, which were dressed, and the patient 
was left with the head elevated, and the attendants requested to keep him in 
that position. 

"10 P. M., same evening. The dressings are saturated with blood, but the 
hemorrhage appears to be abating. Has vomited twice only since being dressed. 
Sensorial powers remain as yet unimpaired. Says he does not wish to see his 
friends, as he shall be at work in a day or two. Tells where they live, their 
names, &c. Pulse 65 j constant agitation of the lower extremities. 

11 14th, 7 A. M. Has slept some ; appears to be in pain ; speaks with dif- 
ficulty j tumefaction of face considerable, and increasing ; pulse 70 ; knows 
his friends, and is rational. Asks who is foreman in his pit. Hemorrhage 
internally continues slightly. Has not vomited since 12 P. M. 

18 Bigelow's Case of Injury of Head. [July 

"16th, 9 A. M. Has slept well half the night. Sees objects indistinctly 
with the left eye, when the lids are separated. Hemorrhage has ceased. 
Pulse 75. 8 P. M., Restless and delirious ; talks much, but disconnected 
and incoherent. Pulse 84, and full. Prescribed vin. colchicum, f 3ss every 
six hours, until it purges him. Removed the night-cap. 

" 16th, 8 A. M. Patient appears more quiet. Pulse 70. Dressed the 
wounds, which in the head have a fetid sero-purulent discharge, with particles 
of brain intermingled. No discharge from bowels. Ordered sulph. magnesia, 
g j, repeated every four hours until it operates. Iced water to the head and 
eye. A fungus appears at the external can thus of the left eye. Says 'the 
left side of his head is banked up/ 

u llth, 8 A.M. Pulse 84. Purged freely. Rational, and knows his 
friends. Discharge from the brain profuse, very fetid and sanious. Wounds 
in face healing. 

" 18$, 9 A. M. Slept well all night, and lies upon his right side. Pulse 
72 ; tongue red and dry ; breath fetid. Removed the dressings, and passed 
a probe to the base of the cranium, without giving pain. Ordered a cathartic, 
which operated freely. Cold to the head. Patient says he shall recover. Pie 
is delirious, with lucid intervals. 

" 19th, 8 P. M. Has been very restless during the clay ; skin hot and dry; 
tongue red ; excessive thirst ; delirious, talking incoherently with himself, 
and directing his men. 

"20th and 21st. Has remained much the same. 

"22d, 8 A. M. Patient has had a very restless night. Throws his hands 
and feet about, and tries to get out of bed. Head hot. Says ' he shall not 
live, long so/ Ordered a cathartic of calomel and rhubarb, to be followed by 
castor oil, if it does not operate in six hours. 4 P. M. Purged freely 
twice, and inclines to sleep. 

" 23<i. Rested well most of the night, and appears- stronger and more 
rational. Pulse 80. Shaved the scalp a second time, and brought the edges 
of the wound in position, the previous edges having sloughed away. Dis- 
charge less in quantity and less fetid. Loss of vision of left eye. 

" From this time until the 3d of October, he lay in a semi-comatose state, 
seldom speaking unless spoken to, and then answering only in monosyllables. 
During this period, fungi started from the brain, and increased rapidly from 
the orbit. To these was applied nitrate of silver cryst., and cold to the head 
generally. The dressings were renewed three times in every twenty-four 
hours ; and in addition to this, laxatives, combined with an occasional dose of 
calomel, constituted the treatment. The pulse varied from 70 to 96 — gene- 
rally very soft. During this time an abscess formed under the frontalis muscle, 
which was opened on the 27th, and has been very difficult to heal. Dis- 
charged nearly ^viij at the time it was punctured. 

" Oct. bth and 6th. Patient improving. Discharge from the wound and 
sinus, laudable pus. Calls for his pants, and wishes to get out of bed, though 
he is unable to raise his head from the pillow. 

" 1th. Has succeeded in raising himself up, and took one step to his chair, 
and sat about five minutes. 

" 11th. Pulse 72. Intellectual faculties brightening. When I asked him 
how long since he was injured, he replied, \ four weeks this afternoon, at half 
past four o'clock/ Relates the manner in which it occurred, and how he 
came to the house. He keeps the day of the week and time of day in his 
mind. Says he knows more than half of those who inquire after him. Does 

1850.] Bigelow's Case of Injury of Head. 19 

not estimate size or money accurately, though he has memory as perfect as 
ever. He would not take one thousand dollars for a few pebbles which he 
took from an ancient river bed where he was at work. The fungus is giving 
way under the use of the cryst. nitrate of silver. During all of this time there 
has been a discharge of pus into the fauces, a part of which passed into the 
stomach, the remainder being ejected from the mouth. 

" 20th. Improving. Gets out and into bed with but little assistance. Sits 
up thirty minutes twice in twenty-four hours. Is very childish ; wishes to 
go home to Lebanon, N. H. The wound in the scalp is healing rapidly. 

" Nov. 8th. Improving in every particular, and sits up most of the time 
during the day. Appetite good, though he is still kept upon a low diet. 
Pulse 65. Sleeps well, and says he has no pain in the head. Food digests 
easily, bowels regular, and nutrition is going on well. The sinus under the 
frontalis muscle has nearly healed. He walks up and down stairs, and about 
the house, into the piazza, and I am informed this evening that he has been 
in the street to-day. — I leave him for a week, with strict injunctions to avoid 
excitement and exposure. 

" l&th. I learn, on inquiry, that Gage has been in the street every day 
except Sunday, during my absence. His desire to be out and to go home to 
Lebanon has been uncontrollable by his friends, and he has been making 
arrangements to that efFect. Yesterday he walked half a mile, and purchased 
some small articles at the store. The atmosphere was cold and damp, the 
ground wet, and he went without an overcoat, and with thin boots. He got 
wet feet and a chill. I find him in bed, depressed and very irritable. Hot 
and dry skin; thirst, tongue coated; pulse 110 : lancinating pain in left 
side of head and face ; rigors, and bowels constipated. Ordered cold to 
the head and face, and a black dose to be repeated in six hours, if it does not 
operate. He has had spiculse of bone pass into the fauces, which he expelled 
from the mouth within a few days. 

" IQth, A. M. No better. Cathartic has operated freely. Pulse 120; 
skin hot and dry ; thirst and pain remain the same. Has been very restless 
during the night. Venesection f^xyj. Ordered calomel, gr. x, and ipecac, 
gr. ij, followed in four hours by castor oil. 

u 8 P. M., same day. Purged freely ; pulse less frequent ; pain in head 
moderated; skin moist. R. Antim. et potassa tart., gr. iij ; syr. simplex, 
f^vj. Dose a dessertspoonful every four hours. 

" 17th. Improving. Expresses himself as ' feeling better in every respect ;' 
has no pain in the head. 

u ISth. Is walking about the house again; says he feels no pain in the 
head, and appears to be in a way of recovering if he can be controlled." 

Remarks. — The leading feature of this case is its improbability. A physi- 
cian who holds in his hand a crowbar, three feet and a half long, and more than 
thirteen pounds in weight, will not readily believe that it has been driven with 
a crash through the brain of a man who is still able to walk off, talking with 
composure and equanimity of the hole in his head. This is the sort of acci- 
dent that happens in the pantomime at the theatre, but not elsewhere. Yet 
there is every reason for supposing it in this case literally true. Being at 
first wholly skeptical, I have been personally convinced ; and this has been 
the experience of many medical gentlemen who, having first heard of the 
circumstances, have had a subsequent opportunity to examine the evidence. 

20 Bigelow's Case of Injury of Head. [July 

This evidence is comprised in the testimony of individuals, and in the ana- 
tomical and physiological character of the lesion itself. 

The above accounts from different individuals, concur in assigning to the 
accident a common cause. They are selected as the most complete among 
about a dozen of similar documents forwarded to me by Dr. Harlow, who was 
kind enough to procure them at my request ; and which bear the signature of 
many respectable persons in and about the town of Cavendish, and all corrobo- 
rative of the circumstances as here detailed. The accident occurred in open 
day, in a quarry in which a considerable number of men were at work, many 
of whom were witnesses of it, and all of whom were attracted by it. Suffice 
it to say, that in a thickly populated country neighbourhood, to which all the 
facts were matter of daily discussion at the time of their occurrence, there is 
no difference of belief, nor has there been at any time doubt that the iron was 
actually driven through the brain. A considerable number of medical gentle- 
men also visited the case at various times to satisfy their incredulity. 

Assuming the point that the wound was the result of a missile projected 
from below upwards, it may be asked whether the wound might not have 
been made by a stone, while the bar was at the same moment thrown into the 
air. It may be replied in answer, that the rock was not split, nor, as far as 
could be learned, disintegrated. Besides, an angular bit of stone wouldhave 
been likely to have produced quite as much laceration as the bar of iron ; and 
it is in fact possible that the tapering point of the latter divided and repelled 
the soft parts, especially the brain, in a way that enabled the smooth surface 
of the iron to glide through with less injury. And assuming the only possible 
hypothesis, that the round bar followed exactly the direction of its axis, the 
missile may be considered as a sphere of one and a quarter inches diameter, 
preceded by a conical and polished wedge. 

The patient visited Boston in January, 1850, and remained some time 
under my observation, during which he was presented at a meeting of 
the Boston Society for Medical Improvement, and also to the medical class at 
the hospital. His head, now perfectly healed, exhibits the following appear- 

A linear cicatrix of an inch in length occupies the left ramus of the jaw 
near its angle. A little thickening of the soft tissues is discovered about the 
corresponding malar bone. The eyelid of this side is shut, and the patient 
unable to open it. The eye considerably more prominent than the other, 
offers a singular confirmation of the points illustrated by the prepared skull 
described below. It will be there seen that the parts of the orbit necessarily 
cut away are those occupied by the levator palpebrse superioris, the levator 
oculi, and the abducens muscles. In addition to a ptosis of the lid, the eye is 
found to be incapable of executing either the outward or upward motion ; 
while the other muscles animated by the motor communis are unimpaired. 
Upon the head, and covered by hair, is a large unequal depression and eleva- 
tion. A portrait of the cast of the shaved head is given in the plate ; and it 

1850.] Bigelow's Case of Injury of Head 21 

will be there seen that a piece of cranuim of about the size of the palm of the 
hand, its posterior border lying near the coronal suture, its anterior edge low 
upon the forehead, was raised upon the latter as a hinge to allow the egress 
of the bar ; and that it still remains raised and prominent. Behind it is an 
irregular and deep sulcus several inches in length, beneath which the pulsa- 
tions of the brain can be perceived. 

In order to ascertain how far it might be possible for this bar of an inch 
and a quarter diameter to traverse the skull in the track assigned to it, I 
procured a common skull, in which the zygomatic arches are barely visible 
from above ; and having entered a drill near, the left angle of the lower jaw, 
passed it obliquely upwards to the median line of the cranium just in front 
of the junction of the sagittal and coronal sutures. This aperture was then 
enlarged until it allowed the passage of the bar in question, and the loss of 
substance strikingly corresponds with the lesion said to have been received by 
the patient. From the coronoid process of the lower jaw is removed a frag- 
ment measuring about three-quarters of an inch in length. This fragment in 
the patient's case might have been fractured and subsequently reunited. 

The hole now enters obliquely beneath the zygomatic arch, encroaching 
equally upon all its walls. In fact, it entirely occupies this cavity ; the poste- 
rior wall of the antrum being partially excavated at the front of the hole, the 
whole orbitar portion of the sphenoid bone being removed behind, as also the 
anterior part of the squamous portion of the temporal bone, and the internal 
surface of the zygoma and malar bone laterally. In the orbit, the sphenoid 
bone, part of the superior maxillary below, and a large part of the frontal 
above, are cut away, and with these fragments much of the spheno-maxillary 
fissure ) leaving, however, the optic foramen intact about a quarter of an inch 
to the inside of the track of the bar. 

The base of the skull upon the inside of the cranium presents a cylindrical 
hole of an inch and a quarter diameter, and such as may be described by a 
pair of compasses, one leg of which is placed upon the lesser wing of the 
sphenoid bone at an eighth of an inch from its extremity, cutting the frontal, 
temporal and sphenoid bones ; the other, half an inch outside the internal optic 

The calvaria is traversed by a hole, two-thirds of which is upon the left, 
and one-third upon the right of the median line, its posterior border being 
quite near the coronal suture. The iron freely traverses the oblique hole 
thus described. 

It is obvious that a considerable portion of the brain must have been car- 
ried away ; that while a portion of its lateral substance may have remained 
intact, the whole central part of the left anterior lobe, and the front of the 
sphenoidal or middle lobe must have been lacerated and destroyed. This loss 
of substance would also lay open the anterior extremity of the left lateral 
ventricle; and the iron, in emerging from above must have largely impinged 
upon the right cerebral lobe, lacerating the falx and the longitudinal sinus. 

22 Bigelow's Case of Injury of Head. [July 

Yet the optic nerve remained unbroken in the narrow interval between the 
iron and the inner wall of the orbit. The eye, forcibly thrust forward at the 
moment of the passage, might have again receded into its socket, from which 
it was again somewhat protruded during the subsequent inflammation. 

It is fair to suppose that the polished conical extremity of the iron which 
first entered the cavity of the cranium prepared the passage for the thick 
cylindrical bar which followed ; and that the point, in reaching and largely 
breaking open the vault of the cranium, afforded an ample egress for the 
cerebral substance, thus preventing compression of the remainder. 

Yet it is difficult to admit that the aperture could have been thus violently 
forced through without a certain comminution of the base of the cranium 
driven inwards upon the cerebral cavity. 

Little need be said of the physiological possibility of this history. It is 
well known that a considerable portion of the brain has been in some cases 
abstracted without impairing its functions. Atrophy of an entire cerebral 
hemisphere has also been recorded. 

But the remarkable features of the present case lie not only in the loss of 
cerebral substance, but also in the singular chance which exempted the brain 
from either concussion or compression • which guided the enormous missile 
exactly in the direction of its axis, and which averted the dangers of subse- 
quent inflammation. An entire lung is often disabled by disease ; but I 
believe there is no parallel to the case in the Hunterian collection of a lung 
and thorax violently transfixed by the shaft of a carriage. 

Taking all the circumstances into consideration, it may be doubted whether 
the present is not the most remarkable history of injury to the brain which 
has been recorded.* 


1. Lateral view of a prepared cranium, representing the iron bar in the act of travers- 
ing its cavity. 

2. Front view of ditto. 

3. Plan of the base seen from within. (In these three figures the optic foramina are 
seen to be intact, and occupied by small white rods. In the first two figures, no attempt 
has been made to represent the elevation of the large anterior fragment, which must 
have been more considerable than is here shown.) 

4. Cast taken from the shaved head of the patient, and representing the present ap- 
pearance of the fracture; the anterior fragment being considerably elevated in the profile 

5. The iron bar of the length and diameter proportioned to the size of the other figures. 

* The iron bar has been deposited in the museum of the Massachusetts Medica 
College, where it may be seen, together with a cast of the patient's head. 

1850.] Frfck on Relations of Dumb- Bell Crystals to Uric Acid. 23 

Art. II. — Remarks on the Relation of the Dumb-Bell Crystals to Uric Acid. 
By Charles Frick, M. D., of Baltimore, Maryland. [With a wood-cut.] 

The pathology of oxalate of lime, and its relation to uric acid, are now so 
clearly understood, and so universally recognized, that it is needless at this 
time to enter into a particular explanation in regard to its formation ; and we 
shall, therefore, take it for granted that, in ascribing its presence in the urine 
to deficient oxidation of the uric acid, we are assuming the correct explana- 
tion. Under the microscope, the most common form that this salt presents 
when it exists as a urinary deposit, is that of double pyramids united at their 
bases, or, as they are usually termed, octahedra; and these at first were the 
only recognized crystals of oxalate of lime. Dr. Grolding Bird, however, in 
his work on " Urinary Deposits," first called attention to some peculiar crys- 
talline bodies having more or less the appearance of dumb-bells, which he 
described as oxalate of lime, and which all observers subsequent to him have 
included under the same head. For many reasons, we were led to doubt the 
correctness of this opinion ; and having had, as we think, an opportunity of 
satisfying ourselves in regard to their composition, we deem it a point in 
pathology of sufficient importance to allow of some brief remarks. It is true 
that the question might easily be settled by chemical analysis, but the infre- 
quency of the occurrence of these crystals, and the minute quantity in which 
they are found, render this test impossible. We think, then, that these dumb- 
bells are not oxalate of lime, but that their presence may be accounted for 
by the disintegration of crystals of uric acid. 

If oxalic acid and lime be added together, the crystals formed under these 
circumstances are always double pyramids, although at times so small as to be 
scarcely perceptible; and, however long the deposit be allowed to remain, 
neither dumb-bells nor ovals are ever found to make their appearance. Whereas, 
if a deposit, consisting entirely of uric acid, be carefully washed, and clear 
water added, we may discover, in a certain number of cases, after the lapse of 
a few days, that dumb bells are present, indicating, beyond a doubt, their 
formation from uric acid without the addition of lime. We were led to 
make this experiment from the following considerations : — We had frequently 
observed in a specimen of urine to which a small quantity of muriatic acid had 
been added, that, after standing a few hours, although crystals of uric acid 
only with a few epithelium scales and a small quantity of mucus were present, 
yet, after the lapse of some days, these same specimens would occasionally be 
found to contain dumb-bells, while the uric acid had either entirely disap- 
peared or presented an amorphous appearance. We were thus shown that 
some relation existed between the dumb-bell crystals and those of uric acid, 
and that their formation was in all probability subsequent to the elimination 
of the uric acid by the kidneys. We then determined to take pure uric acid, 
or at least as pure as it could be obtained from urine by repeated washing, 


Frick on Relations of Dumb-Bell Crystals to Uric Acid. 


and observe, under the microscope, the alterations that it underwent from day 
to day. By setting aside several specimens, and noting the changes that took 
place from day to day, we observed that, in the first place, the rectangular 
crystals had a tendency to become irregularly rounded off at their ends, after- 
wards to be fissured across near their centres in an oblique direction; and, 
finally, these two portions still adherent became rounded off in irregular steps 
towards the periphery of the figure; and this change we have remarked not 
once only, but on several different occasions. Should the crystals originally 
consist of rhomboids rounded off at their oblique angles, we may often 
observe that these first unite at their points — the two longitudinal axes being 
both in the same line — and then by the extreme points falling off, and these 
becoming, by degrees, irregularly rounded, they constitute a variety of the 
dumb-bell crystals in which the concavity of the sides is but slightly marked. 
Another, and, perhaps, the most common form of this transition stage, is 
where one end of the base is fully formed, as is also the union between the 
two, but the opposite head, instead of being round, is elongated to a point. 
More commonly, they are very irregular in shape, but still with resemblance 
enough to a dumb-bell to be sufficiently characteristic. The figures marked 
No. 4 in the wood-cut are of this variety. It is rare for more than one or two 
of these crystals, while actually in the transition stage, to present themselves 
at the same time under the field of the microscope. But within a few weeks 
past we have been fortunate enough to detect, in a specimen of uric acid put 
aside for this purpose, not only the dumb-bells in their formative stage, but 
also several fully formed, as well as some crystals of uric acid almost un- 
changed. This we copied from the field of the microscope, and is represented 

in the wood-cut that accom- 
panies these remarks, with 
the exception of the two 
figures marked four, which 
were observed on another 
occasion ; for without some 
such explanation the change 
we have just been detailing 
could not readily be under- 

Close attention will also 
enable us to observe that 
the ovals usually described 
as separate figures from the 
dumb-bells, are in fact iden- 
tical with them; the apparent 
difference being in reality due to the different planes in which they are seen. 
Some of these are transparent dumb-bells, with a very slight concavity at the 
sides surrounded by an oval, the interval between the two being filled up 

1850.] Frick on Relations of Dumb- Bell Crystals to Uric Acid. 25 

with a black space; while others, again, appear to he dark ovals with a 
small transparent square set in the middle. If these are made to revolve 
on their short axis, it will he seen that one face presents an oval, while a 
section made at right angles to this is a true dumb-bell. Both these forms, 
if the deposit is of any size, are usually seen together, but occasionally one 
only presents itself. 

We are unable to speak with certainty as to the original shape of the uric 
acid crystal which determines the subsequent formation of dumb-bells, but are 
of the opinion that, in a majority of instances, the rectangle, with a height 
nearly equal to its base, more than any other form, is most liable to this trans- 
formation. They are seldom if ever observed at the time of micturition, and 
are in fact very rarely seen. Of the many hundred abnormal specimens of 
urine presented to us during the last few years for examination, we do not 
remember to have seen them but on four occasions, and in each one of these 
the urine had been voided twenty-four hours previously. 

In' his description of these figures, Dr. Bird states that " they are produced 
in all probability by a prolific arrangement of minute acicular crystals" (of 
oxalate of lime). But this we think cannot be the case. There can be no 
lime entering into their composition, for we have shown that their formation 
takes place when there is none of this substance present; but at the same time 
we must acknowledge our inability to explain the exact process that goes on. 
It would seem, however, from the changes exhibited under the microscope, 
that this result is one of simple disintegration. All crystalline bodies made 
up of organic elements have a tendency, by exposure to air or water, to lose 
their clear, distinct outline and sharp edges, and to become amorphous; and, 
in all probability, crystals of uric acid of a peculiar shape have, under circum- 
stances which we cannot yet explain, a tendency to break up and agglomerate 
in certain forms, more or less referable to dumb-bells. 

In connection with this subject, we may mention here a change somewhat 
analogous that occurs in the crystals of the triple phosphate. The phosphate 
of magnesia and ammonia, or, as it is more commonly called, the triple 
phosphate, occurs in the urine under two different forms, one stellar and the 
other prismatic ; and, although both of these present an endless variety of 
crystallization, yet both may be included under one or the other of these heads. 
This difference has been heretofore explained by calling the one a monobasic, 
and the other a deutobasic salt, under the supposition that twice the quantity 
of ammonia was combined in the last in proportion to the other. Our friend 
Dr. David Steuart, of this city, however, has lately called our attention to the 
fact that these crystals may be formed, one from another, by simple aggrega- 
tion. He succeeded in depositing them from the same specimen in both 
forms, and also in crystalline shapes intermediate between the two. This he 
effected by making an acid solution of the phosphate of ammonia and magnesia, 
and then adding very cautiously a drop of ammonia. This precipitates the 
phosphates immediately at the surface, a portion of which fall to the bottom 

26 Morland, Extracts from Soc. for Med. Improvement. [July 

of the glass to be again redissolved. The upper stratum is, after a time, 
gently shaken, when more crystals fall with the same effect. There is a point, 
however, if the solution is not too acid, or sufficient ammonia has been added, 
when some of these crystals remain undissolved, and by carefully setting aside 
the tube at this stage, and allowing it to remain undisturbed for some time, we 
may detect, by the microscope, both the prismatic and stellar crystals with 
their intermediate stages. This experiment we have repeated, and are able to 
substantiate his opinion in regard to the mode in which these formations 
occur. Most of the stellar crystals are of two varieties ; the first being com- 
posed of four rays, and the second of six. In the first we usually find, during 
this process, that, by aggregation of crystalline material, two prisms are formed 
which intersect each other at right angles ; or else two of the rays which are 
in the same line become elongated, and material is gradually deposited in the 
interstices to make up a single perfect prism, the two long arms correspond- 
ing to the length, and the two short to the breadth of the crystal. In the 
second variety, where the figure has six rays, four of these become elongated 
in a similar manner, and the same deposition occurs as in the other ; or else 
these rays are all joined together at their extremities, and the figure then filled 
up constitutes one variety of the prismatic crystal which is very frequently 
observed. These crystals, then, are not dependent upon the difference in pro- 
portion of ammonia in the two, but merely to the rapidity with which they 
are formed; nor is the stellar variety, as has been heretofore stated, indicative 
of a severer lesion than the other. We ourselves have never seen these stellse 
already existing in urine at the time of emission, nor have we ever observed 
them to occur spontaneously. 

The relation of these two forms of phosphate to one another seems to us a 
very interesting point in urinary pathology, and we are of the opinion that 
many of the crystals found in this secretion, heretofore considered as differing 
from one another in their chemical composition, will be found a more accurate 
observation to be formed either by the aggregation or disintegration of primi- 
tive crystals. 

Baltimore, May 10, 1850. 

Art. III. — Extracts from the Records of the Boston Society for Medical 
Improvement. By Wm. W. Morland, Secretary. (With a wood-cut.) 

Feb. 11. — Melanosis of the Eye. — Dr. Bethune reported the following case. 
The patient, a healthy farmer, sixty-five years of age, entered the Eye and 
Ear Infirmary under his care. Twenty years ago, he first observed a red spot 
at the outer angle of the left eye, wedge-shaped, and with the apex towards 
the pupil, as in pterygium. For fifteen years it was stationary ; but five years 
ago it began to grow, and at the end of one year he was only able to discern 

1850.] Morland, Extracts from Soc. for Med. Improvement. 27 

the light. Pain came on, when the disease began to increase, and was severe 
for the first two years ; it was then less again till last autumn, since which 
time it has increased, being occasionally severe and darting, and at times dull 
and heavy. 

On examination, the right eye is well. Lids of left eye separated by a 
black, smooth, but irregular mass, projecting from the anterior third of the 
ball, and compared to a pecan-nut with the base outward and the anterior half 
cut off. A few days after his admission the eye was removed, and at the end 
of a week the parts were healing well, and he was discharged. The eye seems 
to be healthy, except for the tumour, which does not involve the internal parts. 

Under the microscope, Dr. H. J. Bigelow had observed the following 
appearances : " First, numerous cells, apparently epithelial 5 secondly, nume- 
rous cells, of irregular outline, enlarged by a power of five hundred diameters 
to the size of a five-cent piece, and containing sub-cells and nuclei; also some 
of a marked caudate figure. These, with others decreasing to simple nucleated 
cells, with one or two nuclei, the diameter of which cells were only three or 
four times that of blood corpuscles, were probably cancerous. And to account 
for the black colour, the whole field was filled with granules, often aggregated 
into masses resembling Gluge's granulation cells; which last, however, may 
have been the product of independent inflammation. " 

Feb. 11. — Imperforate Vagina. — Dr. J. B. S. Jackson exhibited the 
specimen which he had removed this afternoon, and gave the following account 
of the case. The patient was a respectable unmarried female, twenty-five 
years of age, and well developed in regard to the signs of puberty ; the cata- 
menia, however, had never appeared, and for this she was for a long while 
treated in former years. Seven years ago, the physician, under whose care 
she has since been, was called, and found a tumour in the middle of the abdo- 
men, rising some way above the umbilicus, and feeling altogether like a dis- 
tended uterus; upon each side of this, and extending towards the groins, was 
an elongated and much smaller tumour. On examination by the rectum, the 
cavity of the pelvis seemed to be filled by a tumour as large and solid as the 
foetal head. The external and internal labia were well formed ; but on sepa- 
rating the latter there was found to be a complete closure of the vagina. The 
lateral tumours since that time have been about stationary, but the central 
tumour has varied somewhat in size. Meanwhile, the patient had suffered 
severely from bearing-down and other pains about the pelvis, with consider- 
able dysuria ; the general health, however, was tolerably good, her death at 
last being rather sudden, and connected with some oppression about the chest, 
the cause of which was not ascertained on dissection. In regard to an opera- 
tion, which seemed to have been so imperatively required, a consultation was 
held with two or three professed surgeons when the occlusion was discovered, 
but the opinions were against it. 

On examination after death, the tumours were found as above described, 

28 Moriand, Extracts from Soc. for Med. Improvement. [July 

and also the external organs, except that at the seat of the occlusion there 
were three longitudinal folds, looking not unlike the internal labia on a 
small scale. The parts having been then removed, the uterus and vagina 
were found to be immensely distended, and on incision there were discharged 
three pints of a dark-red, inodorous fluid, resembling venous blood, and with- 
out a trace of coagulum. The two cavities are of about equal size, with a very 
marked contraction midway, corresponding with the os uteri, which, however, 
is in a good measure effaced. The parietes are about one-third of an inch in 
thickness, and quite dense ; muscular structure of uterus developed, the inner 
surface being nearly smooth and without any trace of arbor vitae; vagina less 
smooth internally, and thickness of parietes as great at the seat of occlusion 
as at any other part; the whole thickness of the fleshy mass that separates 
the vagina from the vulva being probably not more than half an inch. 

The Fallopian tubes, which formed the lateral tumours felt during life, are 
distended in proportion to the uterus itself, except at their origin ; the open- 
ings upon the inside of the uterus, however, being large enough to admit a 
small probe. The further extremities terminate bluntly, and the general out- 

line of the tubes is irregular and knobbed. Upon cutting one of them open, 
it is seen to be filled with an uniform, inodorous deep brown substance, not 

1850.] Morland, Extracts from Soc. for Med. Improvement. 29 

very unlike, though harder than, indurated feces. The parietes are thin but 
quite dense ; and towards the uterus the cavity seems as if divided into nu- 
merous compartments by transverse partitions. There are also connected 
with the external surface of the tubes small cysts, filled with a material similar 
to that found in the tubes ; and in the omentum, which adheres partially to 
the tubes, are found one or two other cysts, besides numerous very small 
deposits scattered over its surface, and looking not unlike the result of 

The ovaries are rather large and smooth, and one of them contains a cyst 
about the size of an almond. 

On the following day, the uterus and vagina having been distended and 
the incision nicely closed, a very accurate and highly finished drawing was 
made of the parts for the Society, by Dr. J. C. Dalton ; and from this the 
accompanying wood-cut has been taken. 

Feb. 11. — Aneurism opening into the Trachea. Reported by Dr. Minot. — 
The patient was a female, thirty-six years of age, who had had dropsy for 
fifteen years, and diseased heart for the last four. Five weeks ago, there was 
noted a hoarse cough, dyspnoea, wheezing, and at nights orthopncea, but 
without expectoration or palpitation. These symptoms increasing, she was 
suddenly seized with extreme dyspnoea, the inspiration being easy, but the 
expiration laboured and rattling; pulse 160, and very feeble; whole chest 
resonant on percussion, but with sonorous and sibilant rales in every part. 
From this attack she revived, after a copious expectoration of clear, viscid 
fluid ; but soon had a second. The respiration continued somewhat rattling, 
and always had a peculiar tubular sound, which could be heard at a distance 
from the bed ; she complained, also, constantly of a sense of oppression in the 
trachea. Nine days before her death there came on pleuro-pneumonia ; but 
this seemed to be subsiding, when, after a slight fit of coughing, a torrent of 
blood poured from the mouth and nose, and she died instantly. 

The specimen being shown by Dr. M., there is seen to be some ill-defined 
dilatation of the arch of the aorta, with disease of the parietes, but nothing 
that can be called a sac \ upon the inner surface of the artery at this part 
there is a deep ulcer, four or five lines in diameter, and this had burst into the 
trachea just above its bifurcation; a red, fleshy little mass projecting into 
this last at the seat of perforation. The bronchi were full of coagulated blood, 
and there was also found pneumonia, pulmonary emphysema, old pericardial 
adhesions, and ascites. 

Feb. 25. — Laryngitis. — Dr. Jackson showed the specimen, received from 
Dr. Geo. H. Gay. It was taken from a woman who was attacked very 
suddenly, and died in two days ; she had aphonia, very urgent dyspnoea, and 
dysphagia so severe that she was almost convulsed on attempting to swallow, 
She had been attending upon her sister, who had erysipelas following the re- 
No. XXXIX.— July, 1850. 3 

30 Morland, Extracts from Soc. for Med. Improvement. [July 

moval of a cancerous breast. There is a yellow appearance of the cellular 
tissue, as if from an infiltration of pus, though scarcely any can be forced out, 
affecting the upper part of the larynx, and extending downwards about the 
oesophagus as far as where the parts were cut across, the throat only having 
been examined. The glottis is soft, and not excessively swollen ; and upon 
one side is an appearance upon the surface as if a slough was about to form ; 
the mucous membrane being otherwise unaffected. Dr. J. remarked upon the 
striking resemblance, in regard to the anatomical appearances, between this 
case and one reported by him a few months since (see last number of Journal) \ 
the same appearances he had also found, though to a much less extent, in the 
case of our lately deceased member, Dr. John D. Fisher. (See Boston Med. 
and Surg. Journ., March 13.) He also remarked upon it as an interesting- 
fact, in relation to any question as to the nature of the inflammation in the 
above case, that a third sister has been attacked with erysipelas since the death 
of the second, but is likely to recover. 

Feb. 25. — Paracentesis In Acute Pleurisy. — Dr. Homans reported the case 
which he had recently seen in consultation with Dr. Morrill Wyman, of 
Cambridge. The patient was a healthy woman, and the operation was done 
on the twelfth day of the disease. There was great pain, and such urgent 
dyspnoea that she had been unable for some time to lie down in bed ; with 
enlargement of the side and other physical signs of effusion. An exploring 
needle having been passed in by Dr. W., about an inch below the left scapula, 
3xviij of serum were drawn off, but no pus; and with such relief that the 
patient was able to sleep comfortably that night, in the horizontal position. 
Two or three days afterwards about half as much more was drawn off, and 
recovery soon followed. 

Feb. 25. — Fatty Liver. — Dr. Romans reported the case, which occurred in 
a child between three and four years of age. When about nine months old, it 
began to grow quite fleshy, and continued so ever afterwards. Previously to 
this the liver had been felt to be enlarged, and at the time of death it occu- 
pied the whole cavity of the abdomen. The organ, which is shown, is of a 
very uniform, pale fawn colour, smooth upon the surface, and greasing the 
scalpel; ^ss of oil was also shown, which was obtained from ^iv of the mass. 
The child's health was sufficiently good, except that it was subject to attacks 
of spasmodic dyspnoea ; and it died at last from pneumonia. 

Some years ago, another and rather older child in the same family died 
with an immense liver, but the organ in that case was dark-coloured, quite 
hard, and apparently granulated. There is still a third child, now living and 
about six years old, with enlargement of the organ. The parents and two 
other children appear to be healthy. 

A fractured femur was also shown, from the subject of the present case. 
The bone was broken in the early part of the summer, and again in November 

1850.] Morlancl, Extracts from Soc. for Med. Improvement. 31 

at the same place, and each time the union appeared to be strong. The fracture 
is just below the trochanters, very oblique, and firmly united, though the bone 
is still somewhat vascular ; appears somewhat as if it may have been only 
partially broken. Dr. J. M. Warren, who attended the child in November, 
is confident that the fracture was then complete. 

Feb. 25. — Pleurisy followed by Pneumothorax and Gangrene. — Dr. C. E. 
Ware reported the following case : A young man, thirty-three years of age, 
was taken January 30, 1850, with chilis, cough, loss of appetite, and some 
dyspnoea. He kept about till February 2, when pain occurred in left side, 
greatly aggravated on full inspiration was first examined by Dr. Ware • 
Feb. 4th. He then had a pulse of 84. His tongue was thinly furred, and 
pasty. He had a sharp pain under the sixth rib, with considerable dyspnoea. 
There was less respiration in the left back and front than in the right. 
When up, dull on percussion behind. When lying down, greater resonance on 
percussion over cardiac region than on corresponding part of right side. 
There were no bronchial sounds nor rales. Very little cough, and only an 
occasional expectoration of thin transparent mucus, without stain. 

Qth. His pulse had reached 108. His expectoration was about an ounce 
in the course of twenty-four hours, consisting of tenacious mucus with a 
few blood stains. 

On the 8th, he had become entirely flat on percussion at the base of the 
lung, both before and behind, and there was an entire absence of respiratory 
sound. His pulse was 112. 

10th. His gums were little affected by blue pill, and there was some 
wandering during the night. 

13th. Had a good night; pulse 100. Expectoration very small in 
quantity ; transparent mucus with a few stains of fresh blood j no wandering. 
Puerile respiration and resonance on percussion in right back ; perfectly fiat, 
and no respiratory sound below the spine of scapula in left back, which is 
more full and rounded than right. 

14^. At about twelve o'clock in the night, without any previous warning, 
or change in his symptoms, he was seized with a violent paroxysm of cough- 
ing, and began to expectorate pure pus, of which he raised in the course of 
two or three hours a pint. In it there were a few specks of blood. It was 
attended with great dyspnoea, obliging him to sit up. His countenance 
became quite sunken. His pulse rose to 124. No respiratory sound heard 
in left back ; in front heard as low as third rib. Kespiration clear, without 
rales ) puerile on right side before and behind. 

Ihth. Pulse 104. Expectoration of a pint of pure pus in the twenty-four 
hours, without fetor ; cough frequent, easy, loose \ mind clear. 

16^/i. Had another attack of copious purulent expectoration — a pint in 
two hours ; pulse 120 ; great dyspnoea ; pus more liquid and fetid ; coarse 
mucous rales under left clavicle. 

32 Morland, Extracts from Soc. for Med. Improvement. [July 

18^A. Pulse 112. Expectoration less in quantity, and thicker. Under 
both clavicles resonance on percussion greater than natural in the erect posi- 
tion ; about equal on the two sides. He sleeps very well in the erect position. 

23c?. Pulse 108. Expectoration much diminished, of a less purulent 
character, more thick and tenacious ; respiration pretty easy in a horizontal 
position, which he tried yesterday for the first time since he began to raise 
the pus ; cough much less severe. 

25th. Loud friction sound over the left front above cardiac region. 

28th. Emaciation very great \ expectoration small in quantity, very liquid, 
fetid pus \ respiration more laboured j a strong expiration, with some rale 
over upper part of right front. Great resonance on percussion over whole 
back on both sides, in a reclining position. Under the left clavicle in front, 
a very clear respiratory sound, so closely' resembling a cavernous sound* as 
to make me doubt if it was not so, not being able to tell it by the voice. 

March 1st. No purulent expectoration ; only about an ounce in the twenty- 
four hours of adhesive mucus ; pulse 101 ; general aspect better. 

3d. Pulse 116; respiration more laboured; expectoration purulent, of a 
more unhealthy colour and character, and a decidedly gangrenous odour ; 
over the nates there is a commencing slough. 

7th. Pulse 100 ; tongue clean and moist; slough on back is thrown off • 
expectoration small in quantity, and mucous, except when he is disturbed, 
when he raises a thin, dirty, fetid pus, hawking and spitting it out with 
very little cough or effort. 

Sth. Through the day he gradually failed, and without the occurrence of 
any new symptoms, died early on the morning of the 8th. 

The treatment was in the commencement, leeching, antimony and mercury ; 
and after the occurrence of the pneumothorax, stimulants and tonics. The 
autopsy, owing to circumstances, was made in a hasty and rather unsatisfac- 
tory manner. The chest only was examined. In the left pleural cavity, 
there was by a hasty measurement about forty ounces of thin, fetid, dirty 
pus. The lower lobe of the left lung was entirely carnified by compression. 
The upper lobe in front and at apex was vesicular and healthy, distended 
by air to an almost emphysematous degree. Posteriorly, at about an inch and a 
half to two inches from apex, there was a ragged opening in the pleura, around 
which for an inch or more the lungs had a gangrenous appearance. No 
tubercles or traces of tubercles could be discovered in this lung. There 
were a few adhesions about the lower lobe and at the apex of the upper lobe. 

In the right pleural cavity there was no effusion ; a few adhesions. 
Towards the apex of the upper lobe of the right lung there was a group of 
tubercles. The lung healthy around them. There was quite extensive 
pneumonia of the middle and lower lobe ; hepatization, but apparently recent 
in occurrence. 

* From the post-mortem condition, this was evidently due to the healthy lung, 
floated up to this point by the fluid in the chest, and rendered almost emphysematous 
by compression. 

1850.] Morland, Extracts from Soc. for Med. Improvement. 33 

This case was one of simple pleurisy with effusion in the outset, in a man 
who had never presented any signs of tubercles, and whose family were none 
of them phthisical. Until the fifteenth day from the attack, there was nothing 
peculiar in the course of the disease, and there was no reason to anticipate 
anything unfavourable. Then he was suddenly attacked, without the least 
warning, with violent cough, extreme dyspnoea, and most profuse expectoration 
of pus. The pus, as he raised it, was quite liquid, like that found in a close 
serous cavity, but became thicker on standing. On the 17 th it had become 
quite fetid. From this time he continued on the whole rather improving to the 
twenty-ninth day from his attack, the amount of expectoration varying very 
much — sometimes scarce anything for twenty-four hours, and then suddenly 
very copious. When very small in quantity, it was simple transparent 
mucus. When there was any considerable amount, it was thin, fetid pus, 
similar to that found after death in the pleural cavity, showing distinctly its 
source by its character. From his general symptoms and from the physical 
signs, it is probable that on the twenty-ninth day the pneumonia on the right 
side began under which he sank and died. On that day was also first noticed 
the gangrenous odour in his expectoration. The occurrence of pneumothorax 
except by tubercle, is extremely rare. In the present case it probably 
occurred by tubercle, although none could be discovered, nor anything 
which indicated its previous existence. The gangrenous, ragged condition of 
the lung might easily have effaced or concealed any trace of it. The exist- 
ence of tubercle on the other side adds to the probability of there having been 
tubercle on this also, when it is so difficult to explain the accident in any 
other way. The gangrene would not explain it, as that could hardly have 
occurred in much less than ten days or a fortnight after the communication 
with the pleura took place. There was no odour to indicate it, and the 
pus at the commencement was perfectly healthy in its character, contrary to 
what one would expect to find in contact with a surface undergoing the 
process of gangrene. The gangrene of the lung, the slough on the back, and 
the pneumonia on the right side, all began apparently at about the same time. 

March 11. — Vesicular Disease in a New-bom Infant. — Case reported by 
Dr. Bethune.— The disease appeared on the second or third day, and lasted 
about a week. Upon the upper extremities the vesicles were quite numerous 
and about as large as the head of a pin ; but upon the abdomen, where there 
were only a few, they were probably from four to six lines in diameter. 
There was little or no redness about them, and they at last dried up, causing 
meanwhile nothing more than a little fretfulness. 

Marcli 11. — Painful Cutaneous Tubercle. — Dr. J. M. Warren reported 
the case of a female, thirty years of age, who had a small, projecting nipple- 
shaped tumour on the skin of the right nates. It was of five years' standing, 
and she complained greatly of the suffering, it being of the most insupport- 

34 Morland, Extracts from Soc. for Med. Improvement. [July 

able kind, and occurring in paroxysms. At these periods she would not allow 
any person to come near her. Entire relief followed its removal. Its texture 
was fibrous, and no cancer cells could be detected in it under the microscope. 
The character of the pain was the same as that observed in the subcutaneous 
painful tubercle. 

The wound was examined, after the excision of the tubercle, for the pur- 
pose of discovering if any nervous filament had been pressed upon by it, but 
none could be detected. 

March 11. — Tumour of the Orbit. Dr. J. M. Warren. — Dr. Warren first 
saw the patient two months since, in company with a distinguished physician 
of a neighbouring town. The history of the case is as follows: — 

The patient is sixty-nine years of age, tall, and, with the exception of the 
present disease, healthy. Four years ago, after exposure to a current of cold 
air on his face while sitting at a lecture, he felt a soreness at the upper part 
of the orbit of left eye. Shortly after, a swelling appeared at this spot, and 
this, increasing, gradually filled up the socket, forcing the eye from its situa- 
tion, so as to project it forwards and outwards, and prevent vision, except of 
objects on that side. 

The surface of the tumour was irregular, and covered by enlarged veins. 
It was tense, elastic to the touch, and its appearance at first was that pre- 
sented by encephaloid disease when making its way out from the interior of 
the cranium. 

In the course of two months it had increased one-third. On a careful 
exploration of the tumour, an indistinct feeling of fluctuation was perceptible. 
There was, also, projecting from the upper part of the socket, a small shelf of 
bone which seemed to enter and be incorporated with its parietes. This led 
Dr. W. to the belief that it might be periosteal, and an exploratory operation 
was advised. 

The patient being etherized with chloric ether, an incision was made 
through the skin and orbicular muscle of the eyelid. This at once disclosed 
a sac with an osseous deposit in its parietes, which, on being punctured, dis- 
charged about four ounces of fetid pus. The finger being now passed into the 
cavity, discovered, below, a bony sac, which as far as was practicable was 
'dissected out and removed. On carrying the finger upwards, no resistance 
was encountered until it reached a distance of two inches above the margin 
of the orbit. 

The pressure of the fluid had apparently caused an absorption of the lower 
wall of the frontal sinus, and forced upwards that portion upon which the 
anterior lobes of the brain repose. Two openings could be distinguished 
within the cavity, one leading into the right frontal sinus, the other commu- 
nicating by a very minute opening with the nasal cavities : the interior was 
lined with a delicate membrane. 

After being once emptied, the cavity became again filled with pus, coming, 
as was supposed, from the other sinus. 

1850.] Morland, Extracts from Soc. for Med. Improvement. 35 

The patient bore the operation well, and, when seen some hours afterwards, 
was quite free from pain, and without any unpleasant symptom. 

It was estimated that from six to eight ounces of pus escaped from the 
tumour in the course of the day. This patient was heard from on May 7th, 
nearly two months after the operation. His physician states that some days 
after the operation the discharge was " immense/' Since this, it has gradu- 
ally decreased. The eye has nearly regained its natural position, and he sees 
as well as ever. His health is unimpaired. 

March 25. — Chronic Ulcer of the Stomach. Keported by Dr. W. T. 
Parker. — An Irish tailor, aged twenty-one years, came to this country five 
years ago. Previously healthy, he had an attack of vomiting on his way to 
the emigrant ship. He remained in the harbour six days before sailing, with- 
out any return of it, but during a voyage of seventy days it occurred almost 
incessantly. He landed in Nova Scotia, where the vomiting continued, in 
spite of any medical treatment. For six months he vomited almost daily ; 
and, during that time, was never free from that symptom for more than a fort- 
night. At first, there was nothing peculiar noticed in the character of the 
matters vomited ; after some time it resembled in appearance coffee-grounds. 
The stomach was remarkably distended, having the appearance of a large 
tumour before the act of vomiting, which would occur very suddenly, the 
quantity discharged often amounting to from four to six quarts. During all 
this time his appearance was slightly anemic, his appetite and strength mode- 
rately good, his bowels sometimes costive j the swelling of the stomach giving 
him uneasiness rather than pain. At times able to attend to his trade ; often 
interrupted in it by the exhaustion of vomiting. 

Dr. P. saw him first fifteen months ago, and procured for him a free bed at 
the Massachusetts General Hospital. There he remained under treatment 
four weeks, and was discharged not relieved : the vomiting continuing as 
profuse and exhausting as ever. He came under Dr. P.'s treatment March, 
1849, an aggravated condition of all the above symptoms then existing. 
Syr. ferri iodidi gtts. x, ter in die sumend. was prescribed. 

The vomiting ceased immediately, and strength began to return. 

He persevered in this treatment through the summer months, with such 
relief as to be able to work at his trade, and from the administration of the 
first dose of iron, had no return of vomiting at all, till late in December, when 
a slight attack occurred. This was again relieved by the same treatment. 
During the winter of 1849-50 he had two or three attacks of the same. * * 

March 24th, 1850. Called to him again. Has had a violent return of 
vomiting, attended with unusual pain in the abdomen and swelling. He was 
partially relieved by the warm bath, but collapsed and died in twenty-five 
hours after his last attack. 

On examination, found the abdomen distended by air, and containing nearly 
two gallons of fluid similar to that vomited. Stomach very greatly enlarged, 

36 Morland, Extracts from Soc. for Med. Improvement. [July 

and coats very much thickened, especially towards the pylorus. In the lesser 
curvature, one inch from the pylorus, was discovered an ulcer four lines in 
diameter, which had entirely perforated the stomach, and near it a smaller 
one which had perforated the mucous coat. There were considerable adhe- 
sions between this part of the stomach and the gall-bladder. Further exami- 
nation was prevented. 

March 25. — Poisoning by Nitric Acid. — Dr. J. M. Warren reported the 
case as follows : The patient was a negress, thirty-four years of age, of aban- 
doned character, and took the acid at 6 P. M. on the 3d of March, thinking 
that she was three months pregnant, and wishing, she said, to destroy her 
child. The quantity taken into her mouth was reported to be 3iij, but most 
of it was spit out. Alkalies and mucilaginous drinks were used, but the 
burning in the mouth was intense through the night, with restlessness and 
delirium. The next morning she was brought from the jail, where the acid 
was taken, to the hospital. Yellow stains were then observed upon the cloth- 
ing, and the whole inside of the mouth and fauces, so far as could be seen, 
was of a deep yellow colour, the tongue looking as if covered with Indian 
meal; the respiration being painful, laboured, and stridulous, and speech almost 
impossible. Extremities cold, countenance of a leaden hue; pulse 120, and 
very small. For the first four or five days after her admission she suffered from 
soreness of the mouth and throat, dysphagia, thirst, and salivation, with some 
vomiting j she also complained of tenderness of the abdomen, but not particu- 
larly over the stomach, walking with difficulty and bent much forwards j but 
this was perhaps owing to her having been thrown down and stamped upon, 
in an affray, on the day on which she took the acid. After the first day or two 
she was much of the time up and about the ward ; at the end of a week she 
was reported quite comfortable, and having some appetite j and on the 14th 
of March, as she was doing well, she was removed back to the jail, there 
never having been any fever, but rather a state of depression. On the morn- 
ing of the 16th, she was attacked with cramps in the stomach, and excessive 
pain and tenderness, which were partially relieved by opiates j on the follow- 
ing morning, however, she was found dead in her cell, with a great quantity 
of blood in the bed about her, and which she had apparently vomited. 

On dissection, there was observed great rigidity ; upon the middle of the 
tongue a large, yellowish, smooth patch ; some redness of epiglottis ; oesopha- 
gus healthy for the first two inches ; but below this it was found exceedingly 
soft, of a greenish yellow colour internally, purple externally, and full of 
coagulated blood. The stomach was in a similar, though much worse state ; 
externally, it had the same purple colour, and was universally adherent to the 
neighbouring parts by recent lymph, except at the left extremity, where there 
were old and close adhesions to the spleen ; internally, it was of a greenish 
yellow colour, emphysematous, and so perfectly softened and friable that it 
could not be separated from the surrounding parts without giving way in every 

1850.] Morland, Extracts from Soc. for Med. Improvement. 37 

direction ; the anterior face being detached from the rest of the organ to a 
great extent when the abdominal parietes were raised; cavity filled with 
recent, coagulated blood, and the open orifices of several vessels distinctly seen 
on inner surface. The intestine contained blood throughout the first two or 
three feet ; but was otherwise well, as were the other organs, so far as observed; 
uterus not gravid. 

March 25. — Tumour within the Larynx. — Dr. Jackson exhibited the spe- 
cimen, which he had received from Dr. Augustus Mason, of Billerica. The 
patient was a man about fifty years of age, very fleshy, and in robust health, 
except for the trouble in the throat. For twelve years or more there had 
been hoarseness, with wheezing, and for the last two or three years complete 
aphonia ; there was also much dyspnoea on over-exertion, and, when asleep, a 
distressing noise as from impending suffocation. His death at last was rather 
sudden, and seemed owing to congestion of the lungs. The tumour is about 
seven lines in diameter, well defined, of a rounded form, rough on the surface 
like a syphilitic wart, fleshy in consistence, and having a somewhat fibro- 
cellular appearance on incision. Its situation is just below the ventricles of 
the larynx posteriorly, and it is attached upon each side broadly and to about 
an equal extent, the intermediate portion being free. 

The following microscopic appearances were observed by Dr. W. J. Bur- 
nett : " The primitive original basis of this formation supposed to be an 
epithelial structure. Pavement epithelial cells of various ages were every- 
where plentifully present, being folded in by fibrous tissue; which, as an 
hypertrophy of that normally belonging to the part, is always liable to accom- 
pany the abnormal production of simple individual cell-structures, forming the 
material basis on which the latter rest." 

March 25. — Hydatid Degeneration of Ovum. — -Specimen exhibited, and 
the following report of the case made by Dr. Putnam. — The subject of this 
case is a young married woman. Her last child born three years ago. Men- 
struation since that time regular. Last menstruation occurred during last week 
in November. During the following three months, suffered from pain in the 
back, bearing down, and copious leucorrhcea. There was also an unusual 
degree of chilliness, which made warmer clothing necessary. The above 
symptoms were aggravated at the periods of expected menstruation. She was 
positive that she was not pregnant, because her sensations were different from 
those she had usually experienced during gestation. 

On examination, at the end of the second month, the body of the uterus 
was decidedly enlarged. No special change in the neck. At the end of the 
third month the enlargement was found to have subsided. On the fifteenth 
of March — at the middle of the fourth month— hemorrhage occurred. At 
first very slight, but gradually increasing and attended with pain until the 
twenty-third, when the hydatids were discharged. Hemorrhage continue^ 

38 Morland, Extracts from Soc. for Med. Improvement [July 

more urgently until checked by the use of ergot, but did not entirely cease 
for three weeks. 

The hydatid cluster would more than fill a half pint bowl — the separate 
vesicles being of various sizes, from a pin's head to half an inch in diameter. 
The usual term hydatid has been employed, but it is well known to be a 
vesicular disease of the ovum, resembling hydatids only in external form. In 
this case no foetus was detected, but the deciduous membrane was perfectly 

Dr. Burnett having examined some of these cysts microscopically, found 
the parietes to consist of a simple aggregation of minute granules, such as 
constitute the primary cell membranes, but neither fibrillse, fibres nor vessels ; 
the structure being quite different from that of cysts in general. The 
liquid contents he found to be hyaline, and, in the larger ones, the granules 
were suspended for precipitation upon the internal surface ; the action of acids 
showed the presence of albumen. 

April 8. — Disease of the Radius after fracture. — The case occurred in the 
practice of Dr. Adams, of Waltham, who sent the following history : The 
patient is a healthy married woman, and belongs to a healthy family. Eleven 
3'ears ago she broke the right radius near the wrist, and in about four weeks 
union had so far taken place that the dressings were removed j when, about 
eight or ten clays afterwards, she fell and broke the bone again in the same 
place, as she supposed ; she did not, however, consult Dr. A., and there is 
much doubt as to the second fracture. Three months after the fall she asked 
his advice in regard to an osseous deposition that had appeared at the seat of 
injury ; it was then about the size of a very large bean, and from that time 
continued to enlarge until amputation was performed on the 25th of March. 
During its whole course, the disease gave very little trouble, except from its 
size and the embarrassment to the motion of the limb ; there never having 
been any pain nor tenderness until last November, since which time the pain has 
been gradually increasing until it became so intense as to demand an opera- 

The whole bone begins to enlarge just above the commencement of the 
lower third, and gradually ; but at last forms a tumour nearly as large as the 
two fists ; the general form being pretty regular, though deep grooves are 
seen in its substance, along which run the flexor and extensor tendons. 
Having been sawed through longitudinally, it is seen to be a mere shell of 
bone, and not everywhere continuous; two or three laminae projecting a little 
way into the cavity from its internal surface. This cavity is filled with a soft 
substance, which presents two very different characters : the first and probably 
the most recent has a somewhat fibrous, grayish, translucent appearance, and 
seems to be infiltrated with serum, with a trace of extravasated blood in one or 
two places. The larger part of the mass, however, is made up of a yellow, soft 
and perfectly opaque substance, like soft custard. This last is very marked 

1850.] Morland, Extracts from Soc. for Med. Improvement. 39 

towards the outer edge of the tumour arid just above the wrist-joint, where^the 
bony parietes are destroyed, and the soft parts are shooting out. Dr. H. J. Bige- 
low showed a beautiful coloured drawing of the recent section ; and described 
the microscopic appearances of the new formation, in which he found no 
positive evidence of cancerous disease. The ulna and bones of the hand 
appear to be healthy. 

April 22. — Carcinomatous Tumour weighing fourteen and a half pounds, 
occurring in a little girl only eleven years old. — Dr. Jackson had recently 
examined this case. The abdomen was immensely distended, and measured 
thirty-four inches in circumference. The tumour originated in the cavity of 
the pelvis ; the uterus and rectum being intimately connected, though not 
buried in it; adhesion otherwise not extensive. It consisted of a solid, white, 
rounded mass, one or two lobes upon the surface being felt before the abdo- 
men was opened. Internally, it presented well-marked encephaloid characters., 
the colour being generally white, but the consistence varying somewhat. A 
similar tumour, about the size of the fist, was found near the stomach, but 
none of the organs were affected excepting those of the pelvis ; the ureters 
and pelvis, however, were distended, as they often are, by pressure from 
without. No fluid in peritoneum. 

The patient had been under the care of Dr. W. Lewis, and the history of 
the case was obtained by Mr. S. Gr. Wolcott, one of his students. The child 
was of a lively disposition, and healthy until her fourth year, when, after an 
injury, she suffered from what was regarded as a scrofulous affection of the 
ankle-joint; but from this she recovered, and continued strong and robust 
until she was ten years old, when the disease returned ; and though she after- 
wards improved, she was unable to bear fatigue. In February, 1849, she 
walked two or three miles out of town, complaining of fatigue, and, on her 
return, of great pain in the right iliac region. The abdomen was exceedingly 
distended; and projected, it was said, like a sugar-loaf. For a week she was 
confined to her bed ; after which the swelling subsided, though a hard 
substance remained in the pelvic region about the size of a hen's egg ; and 
this was the apparent beginning of the tumour, which afterwards constantly 
increased. Pain in the iliac region such that she would frequently awake in 
the night with loud screams ; there was also some dysuria, much trouble in 
defecation, frequent vomiting and epistaxis, with night sweats ; her appetite, 
however, was strong, and her constitution bore up well under the disease, so 
that though her whole appearance was delicate, she was able to keep about 
during the winter, being confined to her bed only for about four weeks before 
her death. 

April 22. — Friction Sound over the liver in Ascites, — -Dr. Jackson has 
such a case now in the Hospital. The abdomen has been much distended, 
but as the fluid of late has been absorbed so that the parietes have become 

40 Morland, Extracts from Soc. for Med. Improvement. [July 

relaxed, the left lobe of the liver is distinctly felt for about two inches below 
the ensiform cartilage. If then the abdominal parietes are brought into con- 
tact with this organ, a very distinct though fine frottement is felt by the band, 
and felt or heard by the ear through the stethoscope, as the two surfaces rub 
over each other in the movements of respiration or otherwise. The patient is 
an elderly man, and has no symptoms whatever of peritonitis ; disease of the 
liver being suspected as a cause of the effusion, as it cannot be traced to the 
heart or kidneys, though there is no more positive evidence of the first organ 
being affected than of the two last. 

1 Some years ago, Dr. J. met with this same physical sign in another case of 
ascites j and where it was even more marked than in the one just reported. 
On dissection, he examined the parts very carefully as soon as the abdomen 
was opened, but nothing unusual was found to explain the phenomenon ; the 
liver was granulated, but there were no adhesions, nor any lymph to form 
any, upon the opposing surfaces j the situation of the frottement being the 
same in the two cases. Dr. J. referred to the observations of Dr. Bright in 
regard to a friction sound over the abdomen where adhesions are forming on 
the subsidence of peritoneal inflammation ; observations, however, which he 
had never seen, and which he had never known to be confirmed here. 

April 22. — Encysted Tumour ; removed by Dr. S. D. Townsend, and exhi- 
bited to the Society by Dr. W. E. Townsend. — The patient is forty-five years 
of age, and is sure that the tumour had existed from the time he was a year old, 
if not from birth. It was. situated over the middle of the sternum, loosely 
connected with the surrounding parts, without any discoloration of the surface 
or tenderness ; was of a regular, ovoid form, about the size of a goose-egg, and 
had grown one-half within two years. The cavity was filled with a curdy, 
almost putty-like substance, of a dirty, brownish yellow colour, and formed into 
very uniform, rounded masses, about three or four lines in diameter, with some 
thick liquid, in which were many small, rather bright, scales. Under the 
microscope, this substance appears to consist principally of fat and epithelial 
scales. There are also a considerable number of loose hairs throughout the 
mass. The sac is lined by a well-marked cutis, but, to some extent, by what 
appears at first sight rather like a mucous membrane ; this last being covered 
in part by cuticle. Hairs from two to three inches in length are also seen 
growing from the cutis ; and, whenever seen, they are generally white, though 
some of them are nearly black. 

April 22. — Encysted Tumour. — Dr. H. J. Bigelow had recently removed 
such a tumour from over the upper part of the left scapula. The patient is a 
woman forty-nine years of age, and had had the disease for more than thirty 
years ; occasionally it inflamed and threatened to suppurate, but generally it 
was nothing more than a mechanical annoyance to her. Dr. B. showed the 
material removed from the cysts ; about five or six ounces in quantity, and 

1850.] Dalton's Report on Medical Chemistry. 41 

resembling thick, coarse Indian-meal gruel ; the greater part of it, in fact, 
consisting of opaque, yellow flakes, to the naked eye, and being made up of 
epithelial scales, as appeared under the microscope. He also showed a very 
beautiful coloured drawing of the parts as they appeared before the operation. 

Art. IV. — Annual Report of the Committee on Medical Chemistry. By 
Jno. C. Dalton, Jr., M. D. (Read before the Boston Society for Medical 
Observation, June 4th, 1849.) 

Urate of Ammonia. — The first subject to be noticed in this evening's 
report is the deposit of urate of ammonia from the urine. Though this 
deposit has been noticed by physicians from an early period, and is, perhaps, 
of more frequent occurrence in the urine than any other, yet its exact patho- 
logical signification is not by any means, as yet, fully determined. More 
extensive observations will be necessary to establish definitely the relations of 
this, as of some other urinary deposits j and it is rather for the purpose of 
directing the attention of the society to the matter than because we have 
collected a sufficient number of facts to settle any very important point, that 
the subject is brought forward at present. 

It is stated by authors generally that the deposit of urate of ammonia 
indicates a febrile condition of the system ; and there can be no doubt, from 
the evidence in our possession, that it is, in reality, one of the most common 
phenomena which accompany vascular excitement. Thus, Andral has reported 
thirty-three cases of pneumonia, in seventeen of which urate of ammonia 
occurred as a deposit, either constant or occasional. Simon, also, mentions 
its occurrence in pleurisy, bronchitis, and inflammatory diseases generally. 
Still, this does not show us on what particular circumstance its production 
depends — whether it is consequent on the disturbance of the circulation, of 
the nutrition, or of the digestive organs; or, in fine, whether it results, in 
common with these other symptoms, from the original cause of illness. It 
certainly does not invariably accompany inflammation; and, on the other 
,hand, vascular excitement is not absolutely necessary to its production. 

I have noticed the deposit of urate of ammonia in eleven different cases, in 
some of which the sediment was transitory, in some occasional, and in some 
constant. Two of these were cases of phthisis, three of cancer, one of bron- 
chitis, one of scrofulous disease of the tarsal bones, two accidental injuries, 
one of typhoid fever, and one of sudden and extensive gangrene. Such a list 
as the foregoing, however, can lead to almost no definite conclusion with 
regard to the true cause of the symptom. It is evident that the principal 
disease for which the patients were under treatment may be very different 

42 Dalton's Report on Medical Chemistry. [July 

from the affection which immediately produced the deposit ; and though these 
eleven cases are reported under such various names, yet the appearance of 
urate of ammonia may have depended on the same, or similar causes in every 
one of them. 

The deposit itself presents important varieties in different cases. In three 
instances, it was white or light yellowish in colour ; in eight, red or reddish- 
yellow. In seven it was abundant, in four moderate or slight in quantity. 
The difference in colour is spoken of by nearly all the writers as an important 
circumstance with regard to the signification of the deposit ; as a general rule, 
the red variety being considered as indicating serious disturbance of the sys- 
tem, and the white only trifling or temporary derangement. This rule, how- 
ever, cannot be strictly relied on in the present state of our knowledge. One 
of the three cases in which the deposit was white was that of a mild typhoid 
fever, another of confirmed phthisis, and the third was a case of advanced 
cancerous disease, in which the whole system was invaded by the malignant 
cachexia, and the patient reduced by emaciation, pain, and debility. In this 
instance the urine deposited uric acid constantly, but the urate of ammonia 
varied from day to day in quantity, and was sometimes altogether absent. 

Notwithstanding this, we cannot doubt that the light variety is, in general, 
a less serious symptom than the red. Thus, in two cases in which the urine 
was watched from day to day (one a case of injury of the head, the other an 
acute and extensive bronchitis), the deposit, red at first, gradually grew lighter 
in colour as convalescence proceeded, and at the same time diminished in 
quantity until it finally disappeared. 

With regard to the characters of the urine depositing urate of ammonia, in 
the great majority of cases, viz., eight out of eleven, it was scanty, and mostly 
of high density. In some instances the quantity during twenty-four hours 
was so low as four to five ounces, and the average specific gravity so high as 
1032, 1034, or even 1038 ; so that the urine crystallized freely on the addi- 
tion of nitric acid (nitrate of urea). The urine had an acid reaction in every 
case but one, where it was slightly alkaline, and contained also a deposit of 
phosphates. This happened in the case of injury of the head, and occurred 
on the second day after the accident. The next day, however, the urine again 
became acid, and continued so throughout. Simon mentions the fact that 
urine depositing urate of ammonia, though usually acid, is " occasionally 
neutral, or even alkaline." 

The deposit, in the above cases, was in one instance associated with albu- 
men, in one with uric acid, and in one, as already mentioned, with phosphates. 

As to the accompanying symptoms, it happened that the pulse was rapid 
in only four out of the eleven cases observed ; in the remaining seven it was 
either moderate, or, as in one instance, slow. The skin was hot, warm, warm 
and dryish, cool, dry, and warm and moist. There is, evidently, no approach 
to uniformity in this respect. In two instances the skin and tongue are both 
noticed as natural. With regard to the state of the bowels, pain ; mental con- 

1850.] Dalton's Report on Medical Chemistry. 43 

dition, &c., there was a similar variety. Something more definite, however, 
can be said of the nutrition, since in five of the cases there was strongly- 
marked emaciation, and in none of them was the nutritive function in an 
absolutely healthy condition. This is considered as a very important circum- 
stance by G-olding Bird, who places at the head of his list of causes of this 
deposit a " waste of tissue, more rapid than the supply of nitrogenized food j" 
evidently supposing that the wasted tissues actually appear in the urine under 
the form of urate of ammonia. This opinion, however, must still be regarded 
as somewhat theoretical ; particularly since so great an authority as Simon 
entertains a different idea with regard to the signification of urea and uric 

On the whole, the most constant symptom in the above cases seems to have 
been a disturbance, more or less marked, of the functions of the stomach. In 
seven instances, the appetite was either very poor, or altogether wanting; in 
one it was diminished ; in two it was not reported, and in one it is stated as 
good. In three cases there was frequent and obstinate vomiting, so continu- 
ous and troublesome as to form a prominent feature in the case. 

Those cases in which the deposit was most remarkable for appearance and 
quantity, and most continuous, were four. In another instance, one of ad- 
vanced phthisis, it was strongly coloured and very abundant, and probably 
also continuous j but as I had an opportunity of observing it only once, we 
cannot be certain with regard to the last. The first of the above mentioned 
four cases was that of a man who had an encephaloid testicle removed at the 
Massachusetts General Hospital, Dec. 18th, 1847, while presenting nearly 
or quite a healthy external appearance. His health, which had suffered some- 
what before, immediately began to fail rapidly, and he lost flesh and strength 
daily. His urine, soon after the operation, was observed to become turbid 
after standing, though clear when first, passed. It was diminished* in quan- 
tity, averaging Oj, or a little over in the twenty-four hours, always acid, and 
of a high density, varying from 1027 to 1030. It habitually deposited a 
copious precipitate of bright red urate of ammonia. At the same time there 
was rapid emaciation and loss of strength, failure of appetite, and much pain 
in the back and abdomen, where the encephaloid disease was evidently in- 
vading the internal organs. He died just four weeks after the operation, 
having been reduced in that time to the last degree of emaciation and ca- 
chexia. The abdominal organs in general were found extensively occupied 
by encephaloid disease, but the kidneys were healthy. (In the pelvis of the 
right kidney, which was dilated in consequence of pressure on the ureter by 
a cancerous mass below, were several oxalate of lime calculi.) 

The second case was also one of cancer. It was that of a woman who had 
had a scirrhous breast removed by operation three months previously, and 
who was at the time suffering from well-marked cachexia and general invasion 
of the malignant disease. Emaciation was well-marked, though not rapid • 
much pain in various parts of the body, skin dry, bowels costive, appetite 

44 Dalton's Report on Medical Chemistry. [July 

poor, much thirst, and frequent attacks of obstinate vomiting. Here the 
deposit was white, and associated with uric acid. In this instance, also, the 
kidneys were found natural, though almost all the other organs, and even 
many of the bones, were affected with cancerous disease. 

In the third case, that of Bridget Shea, a patient with scrofulous disease of 
the tarsal bones, there was no emaciation, loss of appetite, or febrile action ; 
but great nervous irritability, with some symptoms of an hysterical character. 
Here, also, there was frequent vomiting, without any very evident cause. 
The patient would vomit two or three times every day — occasionally so many 
as six times of a morning, the appetite meanwhile remaining good. The 
urine in this instance was scanty and dense, and the deposit red, and suffi- 
ciently copious. 

The fourth case was that of an Irishman, whose physical and rational signs 
were such as to leave no doubt that he died of scirrhus of the pylorus, though 
no autopsy was made. This patient was much emaciated, with a dry skin, 
moderate pulse, looseness of the bowels, little or no appetite, and much dis- 
tress at the epigastrium. The vomiting, as might be inferred from the diag- 
nosis, was incessant and uncontrollable. The deposit in his case was red and 
copious, and appeared habitually during a considerable period of time. 

One would be inclined, from a review of these cases, to associate the depo- 
sit of urate of ammonia rather with derangement of the stomach than with 
any other particular disorder. The frequent connection of these two is, indeed, 
acknowledged by nearly all the writers on the subject. Dr. Bird, among the 
five circumstances, which he enumerates as liable to give rise to the deposit, 
mentions failure of the digestive organs to assimilate nitrogenized food. 
Prout speaks of errors in diet, and all irregularities calculated to interfere with 
digestion, as liable to produce it; and mentions particularly the fact that the 
presence of febrile action is not, by any means, essential. He expresses the 
opinion that the organs of digestion and assimilation are, somehow or other, 
concerned in the appearance of these sediments ; but acknowledges that, with 
respect to the immediate nature of these derangements, we still have no very 
distinct knowledge. 

Dr. Prout, however, is here speaking more particularly of the white or 
yellowish variety. The red, he considers, in common with most other authors, 
as almost necessarily connected with febrile excitement. Still, as already 
mentioned, though we cannot doubt this opinion to be correct as a general 
rule, yet the immediate cause of the deposit, even here, may not be the febrile 
excitement itself, but the gastric disturbance which accompanies it. The case 
of Bridget Shea, who had absolutely no febrile action, but much hysterical 
irritability and frequent vomiting, seems to favour this idea. Becquerel him- 
self mentions, with regard to hysteria, that the urine, instead of being copious 
and limpid, is sometimes scanty, dense, and sedimentary. Of these excep- 
tional cases he reports two; in one of which there existed a " slight febrile 
movement ;' ; and in the other, the hysterical attack, as he states, was accom- 

1850.] Dalton's Report on Medical Chemistry. 45 

panied by " gastralgia." (Semeiotique des Urines, p. 370.) The connection, 
therefore, between urate of ammonia and gastric derangement appears to be 
well worth more particular attention, though it cannot, at present, be con- 
sidered as definitely established. 

Iodine. — The next subject to be noticed is the appearance of iodine in the 
urine of patients who are taking it in medicinal doses. That this substance 
does so appear is well known ; and the fact is mentioned by Becquerel, Berze- 
lius, Simon, and Christison. Becquerel comes to the conclusion that it appears 
in the urine constantly, whenever taken into the system, and that its presence 
is very easily detected. The method which he adopts is to mix with the urine 
an emulsion of starch, and add to the mixture chlorate of potass and sulphu- 
ric acid; by which process chlorine is set free by the sulphuric acid, and, 
liberating the iodine from its combinations, allows it to strike the character- 
istic blue colour with starch. Christison recommends the addition of chlorine 
by allowing it to descend, in a gaseous form, from the mouth of a bottle con- 
taining nitro-muriatic acid. In ordinary cases, however, the admixture of 
starch with the urine, followed by a drop or two of nitric acid, to set free the 
iodine, will be found sufficient. 

I have observed the appearance of iodine in the urine in seven cases, and 
in many of them it was detected at the same time in the saliva. In order to 
determine the time which is necessary for iodine to appear in the urine, the 
following experiments were instituted. On the 21st of February, at 5 P. M., 
I took half a drachm of the syrup of the iodide of iron, and examined the 
urine afterward, at intervals of ten minutes. The portions passed at ten and 
twenty minutes past five showed no indication of iodine; but at half past 
five a strong purple colour was produced by the addition of starch and nitric 
acid. This reaction continued throughout the evening, and urine passed at 
seven the next morning struck a deep indigo with the same reagents. At 
9 A. M., the colour was less marked; and from this time it continued to grow 
fainter and fainter, till forty minutes past 4 P. M., nearly twenty-four hours 
from the time of taking the medicine, after which no further reaction was 

The next observation was made with regard to the accumulation of iodine 
in the system, and the time necessary for eliminating a large quantity. 
Two patients in the Massachusetts General Hospital had been taking iodide 
of potassium, one for six, the other for eight weeks. During the greater part 
of this time, they both took the medicine to the amount of one drachm per 
day. On the 24th of February, the medicine was omitted for each. The 
urine of both patients at this time gave a nearly black colour, with starch 
and nitric acid. It was then examined every twelve hours, soon after being 
passed. In seventy-two hours the colour produced was very faint, so that in 
one case it was doubtful whether it existed or not ; and in the other it was 
No. XXXIX.— July, 1850. 4 

46 Dalton's Report on Medical Oliemistry . [July 

distinct on first dropping in the nitric acid, but disappeared by agitation. In 
twelve hours more, all trace of iodine had disappeared from both specimens. 

From these, and other observations, may be deduced the following conclu- 
sions : — 

I. After a single moderate dose, iodine may appear in the urine in so short 
a time as thirty minutes, and continue to appear for nearly twenty -four hours 

II. After a much larger dose, taken habitually for a long period, the time 
necessary for complete elimination is not proportionally increased. 

III. It is therefore probable that iodine, or at least, iodide of potassium, 
does not accumulate in the system in any considerable quantity ; and it is 
questionable whether a large dose, taken habitually, produces any more con- 
stitutional effect than a moderate one, since the superfluity is constantly 
removed by the kidneys. 

IV. The colour, produced by the reaction of starch with uftne containing 
iodine, varies, according to circumstances, from a light purple, slaty-blue, or 
French gray, to deep indigo, or absolute black. 

Y. A solution of iodide of potassium in distilled water, in the proportion 
of one-eighth of a grain to the ounce, produces, with starch and nitric acid, 
an opaque black colour, as strong as is ever observed in urine. A solution in 
the proportion of one-sixteenth of a grain to the ounce produces a strong 
purple, moderately translucent. 

VI. It is therefore probable that iodide is often excreted in the urine in 
about as large a quantity as one-tenth of a grain to the ounce j since one-eighth 
of a grain of iodide of potassium contains nearly one-tenth of a grain of iodine. 

The fact stated in the third proposition, viz., that iodine does not accumulate 
in the system to any great extent, is corroborated by the opinion of Becquerel, 
who states (Semeiotique des Urines, p. 128), that "when its use is continued, 
and particularly when the patient begins to be saturated with it, its passage 
is very abundant, and a large proportion of the iodine introduced into the 
system is eliminated through the urinary passages." The appearance of an 
eruption of acne about the face may, perhaps, be considered as an indication 
that this point of saturation has been reached j and it is thought that this 
effect will, in general, be produced by giving the medicine in doses amounting 
to about half a drachm per day. 

With regard to the rapid elimination of iodine, even after it has been given 
in large doses and for a long time, there is an experiment related by Dr. 
O'Shaughnessy which might seem to weigh against this supposition. The 
instance was that of a dog, poisoned with iodine, in whom the poison was 
detected in the urine so late as the fifth day, though only one dose had been 
given. The drug was administered, however, in this instance, in the form of 
solid iodine, and in the quantity of one drachm ; so that it is possible a part 
of it remained in the alimentary passages for a day or two, without being 
absorbed, and in this way had the effect of repeated doses. 

1B50.] Dalton's Report on Medical Chemistry. 47 

As already mentioned, iodine is usually perceptible in the saliva at the 
same time that it appears in the urine ; hut it does not always exist in these 
two secretions in the same proportions. Thus, in one instance, the urine 
showed only a faint purplish colour by the reagents, while the saliva exhibited 
a strong blue. The same or even greater irregularity was observed by Dr. 
O'Shaughnessy in the case of the dog above referred to, since the poison was 
abundant in the saliva on the third day, but could not be detected in the 
urine : on the fourth and fifth days, however, it again appeared in the latter 
excretion. Becquerel (p. 128) speaks particularly of these occasional varia- 
tions, and acknowledges that we cannot, at present, refer them to any fixed law. 

Hydrocele. — I have had the opportunity of examining the fluid of ten 
hydroceles. The age of the patients varied from twenty-four to sixty years. 
The amount of fluid varied from three to seventeen and a half ounces. The 
average amount of fluid was a little over eleven ounces. It was generally 
clear, and of a yellow, greenish-yellow, or decidedly greenish colour. It was 
neutral in three cases, alkaline in seven. Its specific gravity varied from 
1017 to 1035; the average being 1024.5. In every instance the fluid was 
strongly albuminous, often becoming quite solid and opaque by the action of 
heat. In one instance it also contained an abundance of cholesterin, in the 
form of small crystalline plates, which, floating about in the fluid, and glit- 
tering in the light, had to the naked eye the appearance of oil-globules. The 
fluid of this hydrocele was alkaline, rather large in quantity (^ xviiss), and of 
unusually high density (1035) ; but it presented no other peculiarity. The 
subject was a large, heavy man, with a dark complexion, rather muscular than 
fat, about thirty years of age, and in good health. The fluid had been accu- 
mulating for four years. 

Simon has given the analysis of the fluid of a hydrocele which also con- 
tained cholesterin. It was of a yellow colour, without odour, alkaline, and 
sparkled when shaken, in the same manner as the above. It was also, like 
the above, remarkable for its density, containing fourteen per cent, of solid 
ingredient, which, Simon says, is a larger proportion than he has ever observed 
in any other serous fluid of a similar nature. He reports, also, five other 
analyses, extracted from various authors. In all these cases, the fluid was 
albuminous, and, in most of them, alkaline. 

Gall-stones. — I have also to present to the society several specimens of 
biliary calculi. The first may be considered as a fair type of the most ordinary 
kind of gall-stones; consisting principally of cholesterin, with more or less 
colouring matter, and a minute quantity of calcareous salts. They are, as 
you see, nearly similar to each other in appearance, of a yellowish-brown 
colour ; one to five-eighths of an inch in diameter, polygonal in shape, with 
smooth, roundish facets, separated from each other by blunt edges. Their 
weight varies from one-eighth of a grain to twelve grains. They are lighter 
than water. 

48 Dalton's Report on Medical Chemistry. [July 

Before the blowpipe, they fuse readily and inflame, burning with a yellow 
flame until they are almost entirely consumed, leaving a minute quantity of 
alkaline ash. 

When broken open they are seen to consist, 1st, of an outer, thin, brown- 
ish, brittle layer, under which is another very thin layer of pearly-white 
laminae (cholesterin). Then comes what composes the greater part of the 
calculus, viz., a softish substance, of a dull, yellow colour, crystallized in fine 
needles or fibres, which are collected into cones. The apices of these cones 
project into a central cavity, the walls of which are stained of a dark brown 
colour, and sprinkled with small, white, shining flakes, probably pure 

The frequent occurrence of a central cavity in gall-stones has been pointed 
out by Yogel, who attributes it to the drying and shrivelling up of a mass of 
mucus and colouring matter, which at first constituted a nucleus. 

The above gall-stones were all taken from the body of a woman who died 
in consequence of perforation of the gall-duct. Several calculi had passed 
through into the intestine \ but one, of rather a large size, became obstructed 
in the duct, and produced ulceration and perforation of its walls, and extrava- 
sation of bile into the peritoneal cavity. 

The specimens in the next collection are similar to the foregoing as regards 
their composition. They are remarkable principally for having among them 
many perfectly formed calculi of minute size. 

The next calculus consists almost entirely of cholesterin, with only a very 
small amount of colouring matter and salts. When whole, it was about the 
size of a large walnut, and weighed one hundred and thirty-three grains. It 
is irregularly roundish in shape, with two or three ill-defined facets. It is 
white and brown externally, with a smooth, unctuous feel. It is readily 
inflammable, and leaves hardly any appreciable residue. It breaks readilv, 
and exhibits internally, in a well-marked manner, the peculiar structure, 
partly laminated and partly radiated, which belongs to this kind of calculus. 
It is of a stone-yellow, mixed with white, internally, and presents, in various 
parts, sparkling crystals of pure cholesterin. 

This calculus made its way through the abdominal walls by ulceration, and 
was presented to me by the patient herself, who survived the accident. She 
was a healthy-looking woman, between fifty and sixty years of age. She gave 
the following account of the case. An abscess first showed itself just at the 
right of the umbilicus, and shortly opened spontaneously. Five months after- 
ward, the first gall-stone was discharged. The fistula then remained open for 
six years, at the end of which time the second gall-stone came away, and after 
that the sinus readily healed. It was this second calculus which was presented 
for examination. 

The fourth specimen is of a darker colour. It has a small, roundish 
nucleus, apparently of colouring matter, lying loose in the central cavity. 
This stone resembles the others in composition. 

1850.] Denny' 's Case of Extra- Uterine Foetation. 49 

The calculi in the last collection are somewhat remarkable, both for their 
physical and chemical properties. They were taken from the gall-bladder of 
a healthy-looking man who died of collapse after a severe accident. They 
were very numerous, and these are but a small part of what the gall-bladder 
contained. They are small, irregularly nodulated and jagged in shape, dark 
greenish externally, with a smooth, glazed appearance. They are hard and 
brittle. Internally, black and lustrous, with a fracture like that of anthracite 
coal. They are tasteless, and heavier than water. They are sparingly soluble 
in boiling water, alcohol, and spirit, but communicate to these fluids a light 
yellowish tinge. They dissolve freely in boiling potass, with a dark brown 
colour; and the addition of nitric acid to the alkaline solution produces, after 
a short time, a precipitate of green flocculi (biliverdin). 

Before the blowpipe, the calculus is partially consumed, burning with a 
yellow flame and an animal odor; at the same time undergoing an imperfect 
fusion. It then remains as a grayish-white, friable mass, which produces a 
brown stain on moistened turmeric paper. The fresh specimen effervesces 
feebly with muriatic acid, but is unaffected by acetic acid ; after incineration, 
however, muriatic acid produces brisk effervescence, turning the ash of a black 
colour, and evolving an odor like sulphuretted hydrogen. It appears, there- 
fore, to be principally composed of phosphate, with a little carbonate of lime, 
and a modified form of bile-pigment. 

I have not been able to find in any author an exact description of these 
calculi. Vogel mentions a modification of biliphaein which has a " dark 
brown, almost black colour/' as an occasional constituent of gall-stones ; and 
speaks of a variety of calculus composed almost entirely of this substance, 
which has, moreover, a " mulberry-like" appearance, similar to the present. 
These, however, though almost black, have a decided greenish tinge, and do 
not approach to brown. As Vogel supposes the calculi he mentions contain 
a peculiar modification of the colouring matter, these are probably a variety of 
the same species. 

Art. V. — Case of Extra- Uterine Foetation. By Wm. Denny, M. D., of 
Ellicott's Mills, Howard District, Anne Arundel county, Md. 

In the middle of September, 1840, the subject of the following case, then 
set. twenty years, was delivered of a healthy male child, at full time, after a 
natural labour. Her getting-up was unsatisfactory and protracted ; and 
becoming myself shortly after confined to my house by serious indisposition 
for several months, she passed into the care of another practitioner. In the 
course of the winter, it was reported to me that she was considered to be 
threatened with prolapsus uteri. 

Four or five years after, having in the meantime regained an appearance of 

50 Denny's Case of Extra- Uterine Fcetation. [July 

high health and very considerable embonpoint, she became liable to paroxysms 
of abdominal pain, with distension of the colon and torpidity of the bowels ; 
which attacks I was enabled to relieve from time to time by means of ano- 
dynes and mild but efficient purgatives. A year or two later, she occasionally 
took opiates of her own accord, upon the accession of the paroxysms, some- 
times in injudicious doses, as by the time I could reach her, she presented 
symptoms traceable to the opiate itself. 

In the summer of 1848, as I learned afterwards, she had some anomalous 
symptoms, believed at first to be attributable to a suspension of the catamenia, 
previously regular. Passing some time in Baltimore, she was leeched upon 
the os uteri several times, when, at length, it became the opinion of her medical 
adviser there, as well as herself, that conception had taken place. I saw her 
for the first time under these circumstances, on the 28th of October, 1848, 
when some of the preceding facts were communicated to me. She also 
stated that she had not menstruated since the month of April, had quickened 
about two weeks before my visit, and was now about the end of the fifth 
month of utero-gestation. The enlargement of her abdomen seemed to cor- 
roborate the fact of the pregnancy, as well as the stage to which it was said to 
have advanced. 

From that period until the last of the succeeding January, she was more 
or less constantly sensible of movements within her. She described her sensa- 
tions as identical with those experienced in the last half of her former 
pregnancy, and was confident they arose from foetal motion. Upon one occa- 
sion, she called my attention to these movements, and laying my hand upon 
her abdomen, over her dress, I felt the shock of foetal turbulence so unequivo- 
cally that, although I had abundant opportunities afterwards, I felt indifferent 
to repeat the examination. 

At another time, I applied the stethoscope, also over her dress, failed to 
recognize the pulsations of the foetal heart, but heard what I considered to be 
the bruit de soufflet, clearly pronounced, abruptly terminating at a defined 
line upon the abdomen. 

From the time I first saw her till the last of January, 1849, her abdomen 
enlarged at the rate, and with the characters, of normal pregnancy. When 
the movements spoken of were no longer felt, the growth of the abdomen 
came to a stand. A sensation of " rolling" motion succeeded, particularly 
upon her turning from side to side in bed. " Her breasts had been full of 
milk all winter," but soon after, the lactation receded. 

In November and during the two succeeding months, the paroxysms of 
abdominal pain returned. They were relieved by anodynes, laxatives, and 
external relaxants. About the middle of November, being desirous of ascer- 
taining whether there were present any threats of premature delivery, I 
proposed an examination per vaginam. This was readily assented to, with 
the emphatic declaration, however, that " these pains are in the bowels, and 
not in the womb." 

Bounding the upper part of the vagina, my finger encountered a segment 
of a globular tumour, whose shape, taken in connection with that which could 
easily be made out, through the abdominal walls, proved it to be larger in 
diameter than the brim of the pelvis. It rested upon the brim, and although 
pressed down by a persistent force, was not impacted therein. It only so far 
protruded through the brim as its spheroidal figure differed from a plane. I 
could perceive no alternating impulse like parturient effort. I fancied I could 
feel, through some thickness of interjacent tissue, the form and firmness of a 
foetal head; but so indistinctly then, and so much more so at subsequent 

1850.] Denny's Case of Extra- Uterine Fcetation. 51 

examinations, that I could lay no stress upon the sensation. But the os tineas 
was not in situ. Extending my exploration upwards and backwards, the 
finger became embarrassed, not by any portion of the tumour, but by an 
advance of the posterior wall of the vagina, in a curve from the pubic aspect 
of the rectum, towards the centre of the strait of a large radius, in place of 
the cul-de-sac found there ordinarily. Certain that no os uteri existed, 
centrally, laterally, or posteriorly, I was about to extend my search to the 
point where alone it might be found, viz., high and close behind the ossa 
pubis, but was obliged to desist, then as well as afterwards, in consequence of 
tenderness to the touch complained of in that quarter. 

No further incident is now recollected till the 30th of March. She then 
stated to me that, having had a discharge of bloody mucus for some twenty- 
four or thirty-six hours, pains had come on, differing from those from which 
she had so frequently suffered, that these were alternated with intervals of 
quiescence ; she believed them to be uterine and not intestinal, and she was 
confident that her labour was at hand j nevertheless, as her pains were as yet 
slight, I might retire to another apartment for the present till I should be 
wanted. At daylight in the morning I returned, of my own accord, to her 
chamber, when her attendants reported that there had been no exacerbation of 
the pains through the night, that they had worn off about two hours before, 
since which time she had been quietly asleep. 

On the first of May, she removed to Baltimore, where I visited her in com- 
pany with her medical attendant there, on the 19th of June. She looked thin 
and leucophlegmatic, but her general health was said to be unimpaired. 
She informed me that about a week before my visit, there had occurred a 
sanguineous discharge from the vagina, lasting three or four days, ceasing 
without active interference, producing but little debility, and no sympathetic 

inconvenience. My friend Dr. told me that he had succeeded in 

finding the os uteri, high behind the symphysis pubis, and had also heard the 
placental souffle through the stethoscope. 

I saw her again upon the 16th of August, much altered for the worse. 
She was much more emaciated, and I found her in bed. Within ten days 
preceding, another flow from the vagina had come on, longer continued and 
more profuse than before, weakening her materially, and giving rise to 
constitutional disturbance.* Her abdominal pains had recurred, for which 
she had to resort to large and frequently repeated doses of morphia. On the 
day before my visit, she had been affected with hysterical delirium, whether 
from the morphia or not, I was unable to determine. Both the flow from the 
vagina and the aberration of mind had now, however, ceased. I made another 
examination into the interior of the pelvis, laying my other hand upon the 
bare abdomen. 

The organs therein were in statu quo. I succeeded in reaching the os 
uteri, situated between the tumour and the pubes. It presented, not the 
rounded, dimple-like opening of the gravid uterus at term, but a transverse 
slit, like the mouth of the undeveloped womb, flattened by the compression 
to which it was subjected. A sudden impulse impressed upon the presentation 
through the strait was clearly communicated to the other hand, on the sur- 
face of the abdomen. There was some irregularity in the resistance of the 
tumour through the abdominal walls, but the shape of the body and limbs of 
a foetus could not be made out. 

* The interval between these two occurrences of discharge was nearly eight weeks, 
i. e., two catamenial periods. I believed them to be truly menstrual, and subsequently 
ascertained that such was the opinion of the patient, without, as far as I know, any such 
suggestion having been made to her. 

52 Denny 1 's Case of Extra- Uterine Foetation. [July 

In the meantime, she was desirous of obtaining further counsel upon her 
case. Accordingly, on the 14th of July, 1849, I furnished her with a letter, 
giving an outline history of what had passed under my observation, and 
expressing the opinion I had formed during the preceding winter, that the 
lady was the subject of extra-uterine foetation. I had confidently commu- 
nicated that opinion to more than one medical friend as far back as the first of 

In a reply, dated July 21st, it was stated " that no positive conclusions 
can be arrived at beyond this, viz., that the tumour which distends the 
abdomen is the womb ; that no physical signs of pregnancy can be detected ; 
that the history of the case" (partly given by myself and partly derived from 
another source) " leads to the inference, that the womb is occupied with a 
mass of material, consisting of altered tubular or deciduous coat of the organ." 
This inference was confessedly conjectural, as the case was considered very 

This view of the matter placed me under exceeding embarrassment. I 
gave the communication the attentive and respectful consideration due to the 
distinguished source from which it emanated ; I took a resurvey of the cir- 
cumstances of the case, with all the caution and non-committal I could command, 
and found myself unable to discover any difficulties in its diagnosis, and more 
strongly convinced of my first formed opinion. 

Mrs. returned to reside in my neighbourhood, and came again 

under my charge. Her general health seemed so much deteriorated that I 
had now no doubt that new light would ere long be thrown upon the supposed 
obscurity of the case. 

Though, perhaps, somewhat irregular, I will here transcribe the reasons 
which would not allow me to abandon my conclusions as to the character of 
the case. 

We have in it, suspension of the menses after April, 1848 ; quickening in 
October; foetal motion, relied on by the patient, and clearly recognized by 
myself; the placental bruit; the normal growth of the abdomen, for three 
or four months ; arrest of that growth concomitantly with the cessation of 
motion ; lactation ; and, finally, a simulated or pseudo-labour. 

These circumstances are incomplete as the history of pregnancy, in that, 
1st. I failed to hear the foetal circulation; 2d. I did not elicit fluctuation of 
the amniotic fluid, or the ballottement of the foetus; 3d. The bruit de souf- 
flet is not established to be placental ; 4th. Females and accoucheurs have 
both been mistaken by abdominal movements, in pronouncing upon the exist- 
ence of pregnancy and a living foetus; 5th. At the middle of July, 1849, no 
physical signs of pregnancy could be detected, by gentlemen pre-eminent for 
obstetrical experience, save only the mere enlargement of the abdomen. 

1st. In order to detect the pulsations of the foetal heart, the distal end of 
the stethoscope should be approximated to the thorax of the foetus, with solid 
tissues only intervening. The tic tac is said to be a feeble sound, resembling 
the ticking of a watch heard through one's pillow at night.* The ear of the 
auscultator should be acute and well trained, f and the instrument ought to 
rest upon the bare abdomen. J 

Now there are certain cases in which the face of the foetus looks towards 
the pubis. In such, its chest and abdomen present their front to that space 
on the body of the mother where alone we can avail ourselves of the means 

* Velpeau, see Signs of Pregnancy, Cyc. Pract. Med. 

t Evory Kennedy, see Colombat de 1'Isere, Meigs' edition, p. 570. 

J Dr. Walker's edition of Penman's Midwifery. 

1850.] Denny' 's Case of Extra- Uterine Foetation. 53 

of exploration. Its limbs being gathered up in front, their interstices filled 
with the liquor amnii, must prevent the contact we need for success. 

In other positions, though the thorax of the foetus will be in contact with 
the abdominal walls of the female at one moment, yet floating freely amidst 
the fluid of the amnion, it may frequently change its position, as far as that 
contact is concerned. Much assiduity is, therefore, required, to catch the 
favorable time and place for the recognition of this sign. If the bruit de 
coeur be once made out, then there exists pregnancy, and a living foetus; 
but, from the fact that stethoscopic sounds are occasionally inaudible, even in 
the case of a living and healthy foetus, it does not justify a negative opinion.* 
I consider myself no proficient as an auscultator in thoracic affections. I had 
never used the stethoscope obstetrically before. I applied the instrument 
over the patient's dress, and probably with but little industry in the explora- 

2d. The fluctuation of the amniotic fluid, and the ballottement of the foetus, 
can be best observed between the end of the fourth and the commencement 
of the seventh month of gestation. *j" These signs will depend, altogether, 
upon the preservation of relative proportion in the quantity of the fluid to the 
bulk of the foetus. Now, in one case, there may be but one or two ounces 
of fluid, in another, as many pounds. J An infant at term has weighed only 
five pounds, and another fourteen. 

Under these varieties in the quantity of the fluid and the bulk of the foetus, 
it must often happen that fluctuation and ballottement cannot be elicited, 
The examination should be made in the erect posture. 

Now the patient in this case, though examined about the middle of the 
sixth month of pregnancy, was recumbent j was at the time suffering abdomi- 
nal pain, the abdominal muscles under tonic contraction, by which the tumour 
was jammed down upon the brim of the pelvis sufficiently to mask both fluc- 
tuation and ballottement. 

3d. The bruit de soufflet has been considered to be caused by the rush of 
blood through the arteries of the part where the placenta is implanted. Mo- 
reau seems to refer it to abnormal sound generated in the aorta and its princi- 
pal branches, altered and diminished in their calibre by the pressure of any 
tumour capable of conveying sound more readily than the mass of the abdomi- 
nal viscera. It is quite probable the latter explanation is correct. 

4th. I am aware that females are sometimes confident of having felt foetal 
motion, when their sensations have arisen from other causes than pregnancy ; 
I am aware, also, that accoucheurs of much more tact and discrimination than 
I can lay claim to, have interpreted certain obscure movements as foetal, and 
have afterwards confessed themselves mistaken. But such mistake can only 
occur where the sign itself is confused. Now, if the shock of foetal turbu- 
lence strikes the hand of an observer accustomed to receive it, unequivocally, 
he has the right to rate this sign as strongly diagnostic of pregnancy and a 
living foetus as if he counted the pulsations of the foetal heart. When this 
fact becomes a portion of history, communicated to another practitioner, 
although it may not be unfair, or reflect upon his discrimination, to be told 
that he may be mistaken as others have been before him, it seems too much 
that he should be expected to give up his belief in his own sensations. 

5th. Two and a half months after the probable death of the foetus, and 
three and a half after the simulated labour, there cannot be detected any 
physical signs of pregnancy, save only the local intumescence. 

* Signs of Pregnancy, Cyc. Pract. Med.; London edition, v. iii. p. 484. 
t Ibid, p. 483. % Moreau. 

54 Denny's Case of Extra-Uterine Foetation. [July 

- By the term pregnancy, I understand a process in the human female, 
limited in duration to about nine calendar months. At the end of this 
period, for the most part, delivery ensues. But by reason of a faulty loca- 
tion of the product of conception, upon some other surface than the interior 
of the womb, impossibilities to delivery may be established. Although, in 
such cases, that product may remain for months or years, enclosed within the 
abdominal cavity of the female, yet the relations of pregnancy no longer exist, 
the ovum becoming classified among dead and foreign bodies, accidentally 
introduced amidst living organs. 

In extra-uterine pregnancy, nature seems blind to her own mistake. The 
interior of the uterus becomes lined with decidua; the organ itself is developed 
to twice or thrice its former volume ; the surface of the tissue, to which the 
ovum is attached, takes on the functions of the inner surface of the womb; 
vessels are multiplied and enlarged in the vicinity of the placental adhesion, 
and the arrangement of the capillary loops of both the maternal and foetal 
circulatory apparatus is most probably not dissimilar to that which is esta- 
blished in normal pregnancy. The mammary glands prepare to furnish 
nutriment for a foetus which can never see the light, and finally the vagina 
becomes lubricated, and the contractile tissue of the uterus exerts parturient 

Now, perhaps, for the first time, nature awakes to her error. The con- 
tractions of the uterus necessarily fail of their object, and soon subside. If 
alive to this period, the foetus perishes, it being impossible for foetal life to be 
protracted beyond the full term of utero-gestation. The vascular apparatus, 
hitherto assiduously preserved, by which the elements of nutrition and growth 
had been transferred from the maternal to the foetal system, now becomes 
obliterated. The fluids of the ovum are in progress of absorption. The ovum 
becomes enveloped in a cyst or shell (sometimes found ossified after a long 
period), not unlike the encasement of areolar tissue surrounding a leaden 
bullet, accidentally lodged in the flesh, and for the same object, viz., to pro- 
tect the sensitive structure from the too immediate contact of a foreign or 
dead substance. Lactation may continue or recede, but the organs recently 
developed by the law of gestation, in reference to parturition, assume a retro- 
grade process towards the unimpregnated state; and so perfectly is this some- 
times attained that women have been known again to menstruate regularly, 
nay, have even conceived and borne other children. 

Under such circumstances, the female has no more right to present the 
physical signs of pregnancy, except an enlargement of the abdomen, than if 
she had been duly delivered, five and a half or three and a half months before. 
If, at such interval, the absence of such signs contradicts the existence of 

pregnancy in the case of Mrs. , it would equally contradict it in every 

case of extra-uterine foetation that has ever occurred since child-bearing was a 
process of the human female. 

With these apologies for the defective items in one case, I consider the 
following corollary established. 

The history of Mrs. -'s case is the history of pregnancy. 

It may be seen that I have not urged my impressions of having made out 
the head of a foetus, in my examination in November, 1848. I have not, 
1st, because those impressions were too indistinct to bring them in as an 
argument ; 2d, because they were not confirmed by subsequent examinations ; 
3d, and especially because all the information derived from the exploration of 
the interior of the pelvis belongs to the support of a second corollary. 

If it were stated of a woman, whose uterus was developed to the size it 

1850.] Denny's Case of Extra- Uterine Fcetation. 55 

attains at a period just anterior to quickening, whether occupied by an ovum 
or an amorphous mass, that her os tincee was to be found high and close be- 
hind the symphysis pubis, we should be led to infer that the body and fundus 
of the womb were alone enlarged, that the enlargement would be nearly globu- 
lar (the whole womb being gourd-shaped), that the organ would be contained 
in the cavity of the pelvis, its fundus directed towards the sacrum, below the 
promontory of that bone ; in other words, we should consider it a case of 
retroversion of the womb. At the stage spoken of, whether slowly or sud- 
denly induced, there could not fail soon to happen, impaction from the in- 
creasing mass within its limited bony confines, embarrassment of the office of 
the rectum from the compression, but more than all, occlusion of the neck, 
and overfilling of the cavity of the urinary bladder. Those who have wit- 
nessed, those, especially, who have experienced personally this last affection, 
can appreciate the sufferings arising from it. But there is not only distress, 
but also danger from retroverted uterus. Denman regarded this displacement 
to be secondary to some failure in the timely evacuation of the bladder, and 
accordingly recommended relief to the latter organ, leaving the uterus to 
rectify itself. Other authors, with more reason, give us instruction, besides 
the use of the catheter, to institute such manual assistance as shall lift up the 
fundus of the womb, cause the organ to retrace the steps of its displacement, 
and undergo a sort of artificial quickening. The re-adjustment of the position 
of the fundus uteri necessarily restores the os and cervix to their normal site. 
If proper care be taken afterwards, for a short period, the progressive growth 
of the uterine tumour will prevent a subsequent retroversion and re-descent, 
simply because it soon acquires a diameter larger than that of the superior 

Now, anterior to the quickening in the case before us, no complaint was 
made of impaction, of difficult defecation, of retention of urine, and therefore 
it is fair to infer that there had been no retroversion. But, if there had, 
when the abnormal position of the os uteri was discovered in the middle of 
November, 1848, the abdominal tumour was not only above the brim of the 
pelvis, but was too large to descend below it. From that point of time the 
development progressed, till, to the eye and hand, it presented the character 
of the gravid uterus at term, whose volume is such that the vertical axis is 
from ten to twelve, the antero-posterior seven to eight, the transverse, on a 
level with the insertion of the tubes, nine inches.f The whole womb, from 
being gourd-shaped, ultimately becomes ovoid. The vertical diameter, or 
axis, extends from the os uteri to the middle of the fundus. It occupies nearly 
the position of the axis of the superior strait. Now, the ovoid, standing with 
its axis at right angles to the plane of the strait, its anterior face jutting nor- 
mally against the parietes of the abdomen, and a fundus being recognized at 
some elevated point above the umbilicus, if the os uteri be found, under such 
circumstances, between the tumour and the pubes, without congenital mal- 
conformation, known not to exist in the present case, it is mechanically im- 
possible that the tumour which distended Mrs. 's abdomen could be the 

womb. The intumescence being distinct from the womb, and having been 
proved to be caused by an ovum, that ovum is exterior to the cavity of the 

* Upon a passage in Colombat, in which the author enumerates retroversion among 
the accidents of the later periods of pregnancy, his able American translator and com- 
mentator remarks, that retroversion should not have been placed on this list, because 
towards the close of pregnancy, it is impossible. — Op. cit. p. 36. 

•j- Moreau. 

56 Denny's' Case of Extra- Uterine Fcetatim. [July 

wonib, or, in the words of my second corollary, the ovum of this pregnancy 
is extra-uterine.* 

If the points embraced in the foregoing corollaries are established, what is 
the relative position of the ovum to the womb ? Having never before, in the 
course of more than thirty years' engagement in obstetrical practice, amidst 
a dense population, met with a case of extra-uterine gestation, and ignorant 
of any classification of the varieties of that which is ventral, partly, perhaps, 
because of the absence of authorities from within my reach, I reflected that 
the situation of the cervix and os uteri being similar to that which exists in 
retroversion, in which the uterus revolves from the vertical to the horizontal 
position, upon an axis in its cervix, while the other elements in that displace- 
ment do not present in the case before us, I assumed, as a fact, that the vaginal 
support of the womb was a fixed point in the pelvis. Supposing the ovum to 
be located between the abdominal walls and the anterior aspect of the uterus, 
adherent extensively to the latter, its growth would press the organ down- 
wards and backwards upon the superior strait, while the adhesions might drag 
upwards the os uteri where we had found it ; they would likewise preserve 
the fundus in an approach to its normal upright position, out of the reach of 
ordinary manual exploration. 

To leave this unfounded and perhaps absurd conjecture to stand as it did, 
at the point of time in the history of our case to which we had arrived at the 
commencement of these comments, let us now pursue the sequel of the history 

On the 30th of August, Mrs. again became my patient. She was 

much more emaciated, her complexion was sallow, and her countenance care- 
worn. She suffered greatly from abdominal pain, partly referred to the 
intestines, which were torpid, partly described as cramplike, running from her 
side to the pubis, and at one time as a sensation of something hard, pressing 
downwards within the pelvis. She was obliged to continue the use of large 
and repeated doses of morphia, with occasional laxatives interposed. She 
spoke of some hemorrhoidal sensations in the rectum, and some difficulty of 
urination, the latter always, however, surmounted. Her pulse was accelerated 
(being from 120 to 130 per minute), and small in volume. She had marked 
exacerbations of fever towards evening, followed by profuse sweats at night. 
The hectic aspect of the case, and the resulting dilapidation advanced, so that 
about the middle of September, she did not seem likely to survive many days. 
About the 20th, a free diarrhoea, along with much nausea, supervened, sup- 
posed to be caused by an error of diet, which wasted her flesh, and strength 

* In this bona fide transcript of the arguments which constrained me to dissent from 
the view of the case differing from my own, I was obliged to reason, in support of my 
second corollary, upon the facts, under the general principles of mechanical obstetrics, 
for there were no authorities to which I could conveniently appeal. I was aware that 
very many details of cases of extra-uterine pregnancy were scattered through the peri- 
odicals of the last thirty years, but I lacked the time, and possibly the industry, to wade 
through more than two hundred volumes of those journals, half of them still in pamphlet 
form, to find some analogy with the case before us. 

Searching, afterwards, with an entirely different object, I met with an analytic review 
of " A Memoir on Extra Uterine Gestation, by Wm. Campbell, M. D., of King's College, 

Ed.," from which if I should quote all that seems parallel to the case of Mrs. , 

1 should swell this communication beyond what is already too much extended. Refer- 
ring, therefore, to the number of the "Med.-Chir. Review," for July, 1840, p. 178 et seq., 
where the analysis maybe found, I cannot forbear introducing the following remarkable 
sentences, viz : " When, after the presence of festal movement cannot be questioned, 
the cervix uteri is found directed towards the pubis, so much elevated on the brim that 
it can be felt with difficulty, or cannot be reached at all, there need, generally speaking, 
be little doubt as to the presence of extra uterine gestation." — Op. cit. p. 177. 

1850.] Denny' 's Case of Extra- Uterine Foetation. 57 

still more. In a day or two, however, the diarrhoea abated, when she informed 
me that there had come on a free, purulent, and highly offensive discharge 
from the vagina, along with which, on the first day of its occurrence, were 
some fragments of solid substance. With this discharge the hectic diminished 
materially. She had now so little pain as to dispense with her opiates, and 
her bowels became regular without medicine ; her appetite, sleep and strength 
improved. The abdominal tumour was sensibly diminished. It was tym- 
panitic upon percussion, and no bruit de soufflet could be heard. 

An examination per vaginam had been spoken of by herself, on the first 
day of her return to my neighbourhood, but postponed till she could become 
settled in her new home. When the more serious general symptoms presented 
themselves, I felt no disposition to press an examination, and after the dis- 
charge (the fetor of which was perceptible in the room), occurred, she was 
desirous of waiting till it should cease. The examination, therefore, became 
deferred till the 12th of October. 

At my evening visit on that date, finding her suffering unusually with pain 
referred to the back part of the interior of the pelvis, I made an examination. 

Beyond the sphincter vagina, the enlarged space commonly found seemed 
contracted, its mucous surface turgid and full. I could not pass the finger to 
the point where the os uteri had been formerly reached, not because of any 
closeness between the tumour and the pubis, but apparently from an adhesion 
of the sides of the vagina, just below the os uteri itself. The sphenoidal pro- 
jection at the superior strait was perforated centrally, so as to admit the fore- 
finger freely. The ulcerated passage was smooth and broad, as to its anterior 
face, but posteriorly presented a cleft whose terminus I was unable to reach. 
The vertical measurement of the passage was at least seven-eighths of an 
inch. Above and beyond it, the finger came into immediate contact with the 
head of a foetus, the bone touched appearing stout, and impulse made upon it 
proving no disruption of the head itself to exist. Partly in consequence of the 
distance from the os externum, and partly from surrounding embarrassment 
to a free sweep with the finger, I did not make out any suture. In my efforts 
to do so, I peeled off a portion of soft parts from the bone, which coming 
away on the finger was examined, and found to be a fragment of scalp, ujfon 
which the hair appeared as mature and as thickly set as is usual in the 
majority of children at birth. At subsequent examinations, the length of the 
false passage was diminished, and a suture presenting considerable angularity 
occupied the cleft, now become somewhat divergent. 

On one occasion, the discharge had stopped for some time, and much pain 
was complained of, when the examination was followed by relief from pain, 
with free discharge and audible accompaniment of flatus. Sometimes the 
abdomen was larger to the eye, at which time she would speak of a sense of 
distension, and then an evacuation of gas would lessen the enlargement, the 
discomfort, as well as the tympantic sound. About this time, the lower ex- 
tremities became infiltrated, but the oedema again receded. 

Towards the last of October, having complained for a week or more of 
numbness in the right upper extremity, there came on a sensation ascending 
from the hand to the shoulder, which, from its description and sequence, I 
took to be an aura epileptica. Involuntary twitches ran up the limb, and 
reaching the shoulder, the patient "became blind." This was her own ac- 
count. Her friends stated that then she was thrown into "universal spasm 
with insensibility." I awaited the third and fourth paroxysms, and noticed 
that the precursory aura and local contractions, along with entire consciousness 
and a great deal of alarm, continued for ten or twelve minutes before the ter- 

58 Denny' 's Case of Extra- Uterine Fcetation. [July 

mination in a fully formed epileptic convulsion. Upon the following evening, 
she had four more such attacks, the interval between two of them being not 
more than one or two minutes. An epispastic being applied along the dorsal 
spine, and vesicating well, the convulsions ceased excepting that she had a 
slight one within the next twenty-four hours as she awoke in the night. For 
the two succeeding days, she was agitated all over, but especially in the right 
half of the body, with choreiform contractions affecting the features and speech, 
less than is usual in chorea itself. Any impression made on her mind modi- 
fied this agitation, according as it tended to quiet or disturb her. The jacti- 
tation subsided during sleep, procured by full doses of black drop. 

For a week or more she rallied considerably, but was again suddenly seized 
with a return of convulsion, ushered in with a piercing scream. Throughout 
that night, there was no complete cessation of the spasms, but remissions and 
exacerbations only. In the morning they wore off, when the choreiform 
movements recurred with the recovery of consciousness; and now it was dis- 
covered that the motor organs of the right side were paralyzed, the sensibility 
for the most part being entire. Her face was slightly distorted ; the right 
cheek was benumbed, but the tongue was protruded without obliquity, and 
the speech and intellect were intact. 

Her right leg and foot became oedeniatous ; the partes muliebres and nates 
were reported to be raw and swollen, the one from the acrid discharge, the 
other from pressure added thereto. The next morning, after the announce- 
ment of the paralysis, the obliquity of the features disappeared; but the 
impairment of the motor agents of the limbs remained permanently un- 

For some two or three weeks before her death, cough with much expecto- 
ration became troublesome. The chest sounded well upon percussion, but no 
stethoscopic exploration was made, as it was not possible to make it full and 
satisfactory, from her inability to take or keep a convenient posture. 

On the 15th of November, having once more slightly rallied, the epileptic 
paroxysms returned, and ceasing the next morning, she was left feeble, with 
considerable consciousness, and apparently without suffering, until the 18th, 
about 2 o'clock P. M., when she expired. 

Autopsy, November 19^, 1849, 20 hours after death. — Present Drs. E. C. 
Alexander, Arthur Pue and myself. Weather moderately cool; corpse 
emaciated ; countenance placid. 

And incision was made in the linea alba, from just below the ensiform car- 
tilage of the sternum to the left of the umbilicus, thence extending diverg- 
ently to the middle of Poupart's ligament of either side. Left lateral flap 
slightly adherent to a smooth purplish tumour, occupying all the space ex- 
posed, except where bounded above by the large intestine. Upon the fundus 
of the tumour, there was either a portion of omentum void of fat, or pseudo- 
membrane, from which it could not be distinguished. The cyst being opened by 
a longitudinal incision, the body and limbs of a foetus compactly situated were 
presented to view. The thickness of the cyst was about a line and a half. 
The skin and subjacent soft parts of the foetus were so completely converted 
into adipocire as to resemble hogs' lard, into which the finger penetrated almost 
as easily. Upon lifting it out carefully, the head was found to have occupied 
the lowest region of the cyst, and at the termination of the funis umbilica- 
lis, there was a small volume of shreds, the remains of the placenta, unad- 
herent; but seeming to have occupied a point to the left of the upper and 
posterior region of the cavity.* I thought the foetus felt heavier than its size 

* If my designation of the point, of placental attachment be correct, the bruit de souf- 
flet heard by myself, and also by my friend Dr. afterwards, must have made its 

1850.] Denny's Case of Extra-Uterine Foztation. 59 

indicated. The anterior surface of the cyst was thickly smeared with adipo- 
cire, the detritus of the foetal integuments. The head was much altered from 
its normal shape, but whether from the commencement of disruption before re- 
moval, or in taking it out of and returning it to the abdomen, was not accurately 
noticed. The remains of a scrotum proved the foetus to be male. Its head 
was thickly coated also with adipocire, entirely masking from view the hairy 
scalp. I pointed out to my colleagues an abrasion, from which I had five 
weeks before removed a fragment of the scalp. 

The medical gentlemen present with me concurred that the development 
of the foetus seemed mature. Its longitudinal measurement was not taken 
or estimated, as the body was not laid out at length. It was not weighed, 
but each of us formed an opinion on the subject, not expressed at the time. 
Upon inquiring afterwards, we differed somewhat; but the lowest supposition 
among us was that it would slightly overreach seven pounds. 

The womb and its appendages lay anterior to the cyst, close upon the pubes. 
The former presented its unimpregnated volume, being from two and three- 
quarters to three inches long, about two broad, and something over one antero- 
posteriorly. These organs were sound and natural, excepting that a vesicle 
containing about f5J of yellow serum arose from the left ovary. . The 
sacral aspect of the uterus was closely adjacent and adherent to the anterior 
wall of the cyst; but the ovaries and tubes were free. I opened the uterus 
from its fundus to the os tincae. Its interior was healthy but dark-coloured, 
containing no decidua. If it might be flattened by the long continued com- 
pression to which it had been subjected, there existed no particular attenua- 
tion of either wall, these being each from four to five lines in thickness. No 
rent or cicatrical evidence that this had existed presented itself in the uterus 
or the cyst. 

The most dependent part of the cavity was perforated through into the 
upper region of the vagina, through which the finger passed freely. I did not 
examine into the probability of adhesion in the vagina below the os uteri, in 
consequence of the presence of a member of the family at the dissection, as I 
was unwilling to expose the person of the corpse for that purpose, and I deemed 
the fact of minor importance. 

Remarks. — The result of the autopsy having verified my diagnosis in the 
general, also exposed to me how unfounded had been my conjecture as to the re- 
lative position of the ovum to the womb. I have called that conjecture absurd 
as well as unfounded. Assuming that ventral pregnancies do occur primarily, 
the fcecundated germ fails to enter the osteum abdominale of the Fallopian tube 
because the fimbriated extremity relaxes its grasp upon the ovary, and the 
accurate adaptation of the osteum to the ovisac at the point of its rupture is 
interfered with between the moment of impregnation and the transit of the 
ovule into the tube, the germ, therefore, necessarily becomes misplaced within 
the peritoneal sac, and the ovary being enclosed in the posterior duplicature 

auscultatory track through the body of the foetus, rendering it unlikely that this sound 
can proceed from the causes to which it has been ascribed by Kegaradec. Kennedy, &c. 
Moreover, being heard as late as Mayor June, i. e, one or two months subsequent to 
the simulated labour, strengthening the views of Bouillaud and Moreau, who trace it 
to the modified circulation on the maternal aorta and its branches. Montgomery, also, 
mentions one case of vascular sarcoma, and another of supposed enlargement of the 
spleen, when this sound was clear and distinct. — Cyc. Pract. Med., Art. Signs of Preg- 

60 Denny's Gase of Extra-Uterine Foetation. [July 

of the broad ligament, it would seem imposssible that the error loci should 
cause the ovum to be found upon the pubic aspect of the womb. 

It was perfectly clear that, instead of that part of the vagina into which the 
cervix uteri is implanted being fixed in the pelvis, an ovum, or any other 
growing tumour, located behind the womb is competent to press forward the 
whole organ, along with the superior end of the vagina, and cause the os uteri 
to be recognized, where, during the lifetime of this patient, it had been so 
frequently found. I have now no manner of doubt that, had a careful sur- 
pubal examination been made at the proper time, the outline of the fundus uteri 
might have been traced to distinguish the uterus from the abdominal tumour. 
The neglect in this instance is mine alone, as the proper time would have 
been either during the development of the organ and previous to the pseudo- 
labour, or after the extreme emaciation of the patient. 

Besides this spontaneous call for comment by the autopsy itself, my atten- 
tion has been drawn to another point, by a letter from a medical gentleman 
deservedly standing high both as a teacher and practitioner of obstetricy, con- 
taining some inquiries and suggestions to which it seems to me not improper 
here to reply. 

My friend states " that he has entertained doubts of a perfect and great de- 
velopment of an ovum upon a placento-serous tissue, but that the post-mortem 
details of the above case are almost enough to cause him to abandon those 
doubts." Recurring, however, to a fact communicated to him during the life- 
time of the patient, viz., that at the last of March she had pains and vaginal 
show, he asks, " Were these labour pains ? Did the womb rupture at that 

It does not appear to me possible that rupture of the uterus could have 
occurred upon the occasion referred to; 1st. Because, when the earliest vaginal 
exploration was made, viz., in November, 1848, the os uteri must have been 
where it was subsequently reached, close and high behind the pubis. The 
dissection discloses it there in November, 1849. Why? Because the ovum 
was exterior and posterior to the womb. Now, to suppose that the pregnancy 
had been intra-uterine antecedently to the last of March, 1849, that among 
the events of the pseudo-parturition, the womb had been ruptured and ex- 
tended the ovum from its cavity into the peritoneal sac, is to seek for a work 
of supererogation, as well as to leave the abnormal site of the os tincae, made 
clear by the first examination, unaccounted for. The rationale of this faulty 
position of the os tincae in November, 1849, must be the rationale of that in 
November, 1848. 

2d. Rupture of the womb (an accident which has hitherto, happily, never 
come under my notice) is universally deemed a formidable., not to call it a 
fatal, incident in parturition. Intense shock to the constitution, along with 
external or internal hemorrage, or both, has never failed to attend. The let- 
ter alluded to suggests, however, " that progressive attenuation of a part of 
the uterine parietes sometimes is set on foot during pregnancy, rendering rup- 

1850.] Denny's Case of Extra- Uterine Foetation. 61 

ture an easy occurrence from the contractions of labour, that attenuation might 
proceed to such a degree as to cause the evidences of such an accident to be 
but slight." No doubt this may be somewhat true; but, although such cir- 
cumstance might materially lessen the hemorrhage consequent upon such an 
event, would it lessen the shock ? Does not this arise more from the sudden 
intrusion of the ovum, a quasi foreign mass, into the peritoneal cavity, unpre- 
pared for, and as it were not expecting it, than from the mere laceration of 
the womb itself? 

The pains of the 30th of March were uterine and parturient. The patient 
stated them to be but slight. No exacerbation occurred during my absence 
from her chamber. They wore oiF in a few hours, without any sensation in 
the patient requiring me to be called up, and no hemorrhage of an external 
character accompanied. 

3d. I examined the uterus and its appendages, as carefully as my limited 
anatomical knowledge permitted, and found no attenuation, no rent, no cica- 
trix, or sanguineous effusion. The ventral or abdominal extra-uterine location 
of the ovum must have been established ab origine, and there does not exist 
the smallest evidence that it occurred consecutive to a rupture of the uterus, 
the tubes, or the ovary. 

Writers seem anxious to explain away cases of ventral pregnancy. They 
admit the ovular and tubular varieties of extra-uterine foetation ; in which 
cases the cyst, which at first serves the ovum in loco uteri, is supposed some- 
times to rupture and throw it forth from its first location into the abdominal 
cavity, to form placental attachment where it may. To support this supposi- 
tion they tell us that the rent through which the ovum escaped may have been 
overlooked at the autopsy. Now, although this is to substitute conjecture for 
proof, throwing the onus proband i on those who might be disposed to dispute 
their explanation, it is still a conjecture at variance with the suggested doubts 
of my friend — it being far easier to believe that the product of conception can 
establish a placental attachment when a minute fcecundated germ, than that, 
somewhat developed, it could be detached from its first connections, and then 
go forth to form a new implantation. But have not doubts of the capacity of 
a serous tissue to support an ovum been already cleared away ? 

Blundell says, " I have myself seen a foetus, on the whole not imperfectly 
formed, about the size of six or seven months, and which was taken from a 
boy, where it lay in a sac in communication with the child's duodenum, the 
boy being pregnant. I cannot accede to the opinion advanced by some that 
it is impossible that a foetus should form within the peritoneal sac among the 

Mason Good, also, refers to a case, published in the Med. Ghir. Trans., 
vol. i. page 241, by Mr. Young, "where the nucleus of foetal rudiments 
were found in the abdomen of a male infant about fifteen months old, well 
known, from personal inspection, to nearly all the medical practitioners of 
London;" probably the identical case mentioned by Blundell. 
No. XXXIX.— July, 1850. 5 

62 Bond's Remarlcs on Obstetrical Forceps. [July 

A number of cases of extra-uterine pregnancy, in which the placenta was 
found adherent to the peritoneum, are mentioned also in the work of Colombat 
de l'lsere, for the translation of, and additions to which, the American medi- 
cal public stand under such enduring obligation to Professor C. D. Meigs, of 

Art. VI. — Remarks on Obstetrical Forceps, with an attempt at their Im- 
provement. By Henry Bond, M.D. (With three wood-cuts.) 

At an early period of my professional life it occurred to me that obstetrical 
cases are sometimes, although not very frequently, met with where the use of 
the forceps is clearly indicated, but where the instrument is found defective. 
I refer to those cases where, owing to the position or the form of the foetal 
head, and its relation to the pelvis, it is found impracticable to adapt the clams 
to the head so as to lock the branches, or to do so without violent injury to 
the mother or child. There is probably no obstetrician of large experience 
who could not furnish ample illustrations of this opinion, if he would give a 
full and faithful detail of his observations. 

Systematic writers tell us that " we must feel the ear," or otherwise deter- 
mine the precise situation of the head, and then the blades "must be placed 
exactly upon the parallel* sides of the head, so that they may lock — if the 
handles do not readily join upon the introduction of the second blade — then 
we must, by judicious management of the one in fault, make it join its fellow." 
We are directed to withdraw the blade in fault and introduce it again, as if 
that would certainly accomplish that exact adaptation. When the head is 
above the brim of the pelvis, where the use of the forceps is sometimes clearly 
indicated and urgently demanded, it is an empty pretence that we can always 
determine the exact position of the head, and not less so, that " judicious 
management" will always enable us to adapt the blades exactly to symmetrical 
portions of the head so as to lock readily. Dr. Blundell says, " they (the 
long forceps in such cases) are more generally laid over the forehead and 
occiput." See also Velpeau, sect. 1061. 

I will here present, very briefly, a few illustrative cases. 1. In the early 
part of my practice, I was called to a patient who was attacked with very 
violent puerperal convulsions. I requested a friend to come to my aid, bring- 

* This term parallel, as employed by some obstetrical writers, is not used correctly. 
There are no parallel sides of the head, but there are symmetrical sides or portions, using 
this term in its geometrical acceptation. The term opposite will not express their idea 
in this case, because the frons and occiput are opposite, but they are neither parallel nor 
symmetrical. The terms similar and correspondent may express the idea, but their im- 
port is more vague — less precise and technical than symmetrical. 

1850.] Bond's Remarks on Obstetrical Forceps. 63 

ing a forceps with him. We made repeated attempts to apply the instrument, 
and with a similar result — we could not lock the branches. We then sum- 
moned to our aid a gentleman of much experience and repute as a teacher of 
obstetrics. He introduced the blades, and he found them no nearer to an ap- 
position, that admitted of locking, than we had done. But, as a professor 
must not be thwarted in the exercise of his own art, and, moreover, as the case 
was very urgent, with a strong hand he made them lock, and soon delivered 
the child ; but the temporal artery was wounded, the cranium was fractured, 
and the child was not a long time dead. 

2. In a case where the use of the forceps seemed to be indicated, and where 
the head was above the upper strait, I called to my aid a gentleman of emi- 
nent skill and great experience. We both attempted to apply the instrument, 
and with equal want of success. We could not adjust it so that the branches 
would lock, or that we could obtain any command of the head. The vectis 
was also tried without success. The case was very urgent, and we were 
obliged to resort to embryulcia. This is the only instance in which this 
operation has been resorted to in a patient of mine, in a practice of thirty-three 
years. Owing to the disproportion between the dimensions of the head and 
the pelvis, it is, indeed, problematical whether the delivery could have been 
accomplished by means of the forceps, if it could have been adapted to the 
head, so as to lock; but it was very desirable to try the problem. 

3. A few years ago I had a case, where, in consultation with a friend, it 
was deemed necessary to use the forceps. The head was above the upper 
strait, and I found it impossible to apply the instrument so as to lock the 
branches. I then made the female branch bear upon the pivot without lock- 
ing, allowing the clams to be adapted to the head obliquely in their relation to 
each other ; and using my hands as a lock, with much care to prevent slipping, 
I succeeded in safely delivering the child. If I had forced the branches to 
lock in this case, some violence must have been inflicted on the mother or 
child. This case, apparently so simple and devoid of striking incidents, was 
to me a very instructive one. 

4. A case occurred recently in this city, as I have heard, where, owing to 
the difficulty or impossibility of properly adapting the forceps, the superciliary 
ridge was fractured and the eye destroyed. A similar case is mentioned in 
Dewees' Midwifery. These belong to that too numerous class of cases, the 
details of which are seldom allowed to escape the confines of the darkly shaded 

Dr. Blundell very justly observes, u Unless the blades be elastic, absolute 
adaptation can (I conceive) never be obtained ; for while the form of the in 
strument remains unchanged, that of the head itself varies/' " The lock 
should be loose, so as to admit of a junction of the blades, although they may 
not be brought into exact apposition with each other ; for, in applying them 
to the head, this adaptation cannot always be obtained." For this reason, he 
says that Smellie's lock (made loose) is decidedly the best. 

64 Bond's Remarks on Obstetrical Forceps. [July 

Dr. Meigs says, " If we fail to adjust the branches accurately in apposition, 
we either cannot make them lock, or we lock them in such a way that the 
edge of the instrument contuses, or even cuts the part of the scalp or cheek 
on which it rests, leaving a scar, or actually breaking the tender bones of the 
cranium, while the other edge cuts the womb or vagina by its free projecting 
edge. In fact, the forceps is designed for the sides of the head ; and if, under 
the stress of circumstances, we are compelled to fix them in any other position, 
[an incident not very unfrequent], we shall always feel reluctant to do so, and 
look forward with painful anxiety to the birth, in order to learn whether we 
have done the mischief we feared, but which we could not avoid."* 

The difficulty and the danger in such cases evidently arise, to a great ex- 
tent, from the want of an accommodating, rocking motion of the branches of 
the forceps upon each other, such as will allow the depressed ("cutting and 
contusing") edge to rise, and the elevated edge to sink and come in contact 
and apposition with the head ; that is, so that the blades may be adapted to 
the head by varying from their usual relation to each other. 

None of the French forceps, or their numerous modifications, so far as I 
know, are intended to admit of such a motion. When locked, they are truly 
locked ; and whatever be the form of the head, or • whatever the parts of the 
head to which the instrument is applied, the head must conform to the forceps 
and not the forceps to the head. Smellie's joint (which can hardly be called 
a lock) will admit of some motion, if made loose, as recommended by Dr. 
Blundell ; but this motion is very limited and unregulated. Dr. Davis, of 
London, has adopted Smellie's joint, but without observing Dr. Blundell' s 
precaution as to its looseness. The lock of Dr. Siebold's forceps, when the 
pivot is partly unscrewed, will admit of the lateral motion of one branch upon 
the other, to a very considerable extent. The branches of forceps are two 
levers of the first kind, the pivot being the common fulcrum of each. It is 
to be observed in Siebold's forceps, that the branches are so much curved — * 
make so wide a sweep — that the fulcrum is far removed from the direct line 
between the power (the hand) and the weight (the head) ; and it will be seen 
on examination that this circumstance will render their lateral or rocking 
motion nearly useless, if not dangerous. Indeed, I should infer, from the 
structure of the joint and the form of the blades, that the use of this motion 
was never contemplated by the inventor. 

A forceps was exhibited to the profession in this city, several years ago, 
devised with a view to supply a rocking, accommodating motion. It was con- 
structed with a swivel joint in each shank, allowing motion to a limited extent. 
The objections to it were, 1st. That this joint rendered the blade very weak, 
and that it would almost unavoidably become corroded with rust. 2d. That 
the operator had no control over the motion of it ) it would rock or wabble 

* See " Obstetrics; the Science and the Art" chap, xv., for much information and excel* 
lent lessons on the use of the forceps. I commend attention to the author's emphatic 
inculcation of the idea, that the forceps is the child's instrument. 

1850.] Bond's Remarks on Obstetrical Forceps. 65 

always, whereas the rocking motion is not commonly requisite. This unre- 
stricted motion, together with the form of the blades, would render this in- 
strument very liable to slipping or displacement. I have forgotten the name 
of the inventor, and I am not aware that there is a specimen of the invention 
in this city. 

In the instrument,* which is illustrated in Figs. 1, 2, 3, I have attempted 

Fig. 1. Fig. 2. Fig. 3. 

to supply what has seemed to me an oovious desideratum, viz., to give the 
branches of the forceps an accommodating rocking motion upon each other, the 
extent of which can be regulated at ivill, and which shall in no respect lessen the 
power of the instrument. The mechanism devised to obtain this motion is 
very simple, not liable to derangement, and it may be adopted in the con- 
struction of forceps of other forms than that here presented ; provided that 

* The instrument, from the manufactory of Messrs. John Rorer & Sons, of Philadel- 
phia, is made of German steel, and spring-tempered 

66 Bond's Remarks on Obstetrical Forceps. [July 

the pelvic* curvature of the branches does not take such a wide sweep, as to 
throw the pivot far out of the direct line between the handle and the centre 
of the fenestrse. 

The instrument will be seen to differ, as a whole, from any now in use ; 
although no one of its modifications, except the lock, has any claim to novelty. 
The handles are Dr. Siebold's, with unimportant modifications. The blades 
are Dr. Davis's a little modified. Its whole length is about fifteen inches, 
and its weight about fifteen ounces. The length of the handle is six inches, 
and that of the blade nine inches. It might be made somewhat shorter and 
lighter without impairing its power. 

Of the Loch. — In Fig. 1 (the pivot of full size), the screw is of about double 
the diameter and nearly double the length of those in other instruments. 
This additional strength is necessary, because the bearing point of the pivot is 
not immediately above the blade in which it is inserted (as in other instru- 
ments), especially when this bearing point is elevated so as to give the blades a 
free rocking motion. The additional length is required to give the screw a 
firm lodgment, when it is partly withdrawn from the blade. The thumb-piece 

* There being some vagueness and discrepancy in the use of the terms employed in 
describing the obstetrical forceps, I here offer some explanatory remarks. These may 
be entirely superfluous to many readers, but perhaps not so to all. 

A forceps consists of two branches (brachia) and a pivot or fulcrum (that is, in such 
forceps as have their branches connected by a pivot). A branch consists of the handle 
(manubrium), which extends to the joint (junctura), and of the blade (cochleare), which 
extends from the joint to the remote point. The blade consists of the clam (cochlea), 
which is that concave portion of it intended to embrace the head, and the shank (femur), 
that portion between the joint and the clam. This division of the blade into shank and 
clam is not recognized by Mulder, but it has become very convenient if not abso- 
lutely necessary. The two parts of the clam, on the sides of the opening or fenestra, are 
sometimes called the limbs of the blade, viz., the upper limb, and the under or outer limb. 
The pivot consists of the thumb piece, the screw, and the intermediate bearing point or ful- 
crum. When the branches are connected by a pivot, they are usually designated as the 
male and the female branches ; that which has the notch for the reception of the pivot, 
being the female and the other the male branch. 

Dr. Velpeau designates the two branches as the right and the left, from the position of 
the handles as held in the hand of the operator. It seems to me more appropriate to de- 
signate them from the position of the blades, these being the more essential parts of the 
instrument, and the attention, in an operation, being directed more to the position of the 
blades than to that of the handles. Otherwise the blades seem to be playing at cross- 
purposes — the right blade being on the left, and the left on the right. I am aware that 
it may be said, in support of that usage, that the branches are named right and left, in 
reference to the pelvis of the patient. For the same reason, when riding backwards in 
a coach, a man's right hand becomes his left. 

As one curve of the forceps is made in reference to the form of the head, and the other 
to that of the pelvis, it seems to me more distinctive and suggestive to name them re- 
spectively the cranial and the pelvic curvatures, than the old and the new curvatures. This 
was new in the time of Levret, but it has ceased to be so; and we do not derogate from 
the credit of the inventor of that important improvement by giving it an expressive 

1850.] Bond's Remarks out Obstetrical Forceps. 67 

is made to fit so close upon the female blade, but without resting upon it, and 
is so thick and rounded, that there may be no risk of injury should it ever 
happen to be brought into contact with the patient. The screw, when well 
made, will turn so easily that the thumb-piece may be made much less promi- 
nent than it is here represented. When the forceps. is used, the thumb-piece 
should be placed parallel with the blades ; otherwise it may interfere with the 
rocking motion. Between the thumb-piece and the screw, the pivot is of the 
form of two frusta of cones of equal dimensions, united together at their 
smaller diameters, forming an obtuse angle or groove at their junction. The 
base of that cone joined to the screw projects a little, forming a shoulder, 
intended to limit the motion of the screw into the blade. 

The notch in the female blade, made to receive the pivot, is so deep that 
the pivot, in relation to the edges of the branch, is nearly in the middle ; yet 
the width of this branch, opposite to it, is swelled out, so as to give it adequate 
firmness. The width and the form of the sides of the notch are accurately 
adapted to those of the pivot, and the bottom of the notch terminates in an 
edge, like the knife-edge of a balance, which is intended to rest in, and bear 
upon, the angle or groove in the pivot. On the under side of the male blade 
is seen a protuberance, finished so as to present no salient points. It is a 
shield for the extra length of the screw. When the pivot is screwed entirely 
down, the branches have no more lateral or rocking motion than those of any 
other forceps, and, in this condition, they will very generally be used. But 
by turning the screw, so as to elevate the bearing point, more or less freedom 
is given to the rocking motion, according to its elevation ; and this motion is 
effectually restricted within any desired limits. When, by means of this free 
motion, the operator has been enabled to grasp the head, he may sometimes 
change its position, so that the clams may be then adapted to the head, with- 
out the obliquity at first necessarily allowed to them by the elevation of the 
pivot ; and then, if desirable, the pivot may be screwed down, and the blades 
will become as fixed as those of other forceps. 

Two objects seem to have been kept more or less in view by the various 
modelers of the obstetrical forceps. One of these objects has been efficiency, 
having reference chiefly to the certainty of accomplishing the delivery. Of 
this sort is the long heavy French forceps, and to some extent its several 
modifications. It is undoubtedly a powerful, but dangerous, instrument. 
The narrowness of the blades allows them to be introduced with comparative 
ease to the operator, and then (with such powerful levers, as their long 
handles) also to be locked with apparent ease, without being adapted to the 
head. They must be efficient in the hands of a bold operator in effecting " a 
triumph of the art," but, like other victories, too often attended with havoc* 
The other of these objects has been safety, especially for the child. Dr. Davis, 
of London, seems to me to have had this object especially in view in model- 

* See Blundell's " Obstetric Medicine," part ii., chap, viii., sec. 3. last paragraph. 

68 Bond's Remarks on Obstetrical Forceps. [July 

ing his forceps, and to have been so engrossed with it that he has not had 
a due regard to efficiency. Such blades as his, in awkward, inexperienced 
hands, and indeed in any hands, are probably less easily introduced so as to 
be locked than the French forceps j because, for the purpose of locking, they 
require a more exact adaptation J but when applied they are much safer — 
there will be much less probability of injuring the child. The French forceps 
have received several successive modifications in this country, which add much 
to their safety and convenience. Indeed some accoucheurs extol some of these 
modifications as the ne plus ultra and almost the sine qua non of obstetrical 

It will be seen that the blades of those here presented (Figs. 2 and 3), 
resemble nearly those of Dr. Davis. The shanks are considerably longer ; the 
clams are not quite so long ; the radius of their pelvic curvature is a little 
less, especially that of the outer limbs, so that it will be less liable to be 
obstructed by the promontory of the sacrum, in passing the instrument above 
the superior strait. The fenestras are wider in their middle and posterior 
part than those in most other forceps now in use. When the pivot is ele- 
vated, so as to allow the blades their rocking motion, this width becomes 
especially requisite in order to secure a firm hold on the head, and to avoid 
the risk of their slipping sideways. The space between the blades is such, 
that, when applied to the head, the handles shall not be at a distance from 
each other, awkward and inconvenient to the operator. From the pivot, the 
upper line of the shank continues forward, without any elevation or depression 
to the beginning of the pelvic curvature ; and the form and the relation of 
the shank to the clam are intended to be such as to interfere the least with the 

While a form has been selected, which, it is believed, will admit of applica- 
tion easy and safe for the mother and child, and grasp the head above the 
superior strait, it will be seen (Fig. 2) that the pivot is in a direct line 
between the handles and the centre of the fenestras. This is a point of import- 
ance in those cases where the rocking motion of the blade may be required, 
as it will cause each limb of the clams to press with nearly equal force, thus 
avoiding undue pressure upon any one part of the head, and the liability to 
slipping or displacement. 

The handles are made partly of ebony, and they resemble those of Siebold, 
although considerably lighter. The precise model, of those represented in 
the illustration, is not important ; for it may be varied to suit the grip or the 
taste of different operators. The objects aimed at in their construction should 
be, first, such a length, compared with that of the whole instrument, as to 
give a sufficiently firm hold and pressure upon the head, without inflicting a 
dangerous compression ; and, secondly, such a form as to allow them to be 
easily grasped in the hand of the operator, with the full assurance that he 
has the best command of the instrument, without the danger of slipping, and 
without the necessity of a napkin envelop. These qualities do not belong to 

1850.] Bond's Remarks on Obstetrical Forceps. 69 

the long polished steel handles, which are heavy, upon which the wet, oiled 
hand of the operator must slip, and which, even when encumbered with a 
napkin, must convey an uncomfortable sensation of misgiving. Ask the 
lithotomist or amputator how he would like to have his instruments finished 
with such handles that he would be obliged to grasp them wrapped in a 
napkin? One prominent objection, if not the chief one, to Dr. Davis's for- 
ceps, is the shortness of the handles and their uncomfortable grip, except in 
a hand inconveniently large for an accoucheur. They cannot, however, slip 
in the hand, like those of polished steel. 

The attempts to combine several other instruments in the handles of the 
forceps, I regard as, generally, worse than useless. "With the long polished 
steel handle may be combined an efficient blunt hook. But with such a heavy, 
mis-shapen handle, the operator would be much more liable to injure the 
mother or child than with a well-constructed blunt hook. I refrain from any 
criticism upon such useless perforators and dangerous crotchets as I have seen 
combined with forceps. It is sufficient for an instrument, so important as the 
forceps, that it is exactly fitted for the performance of its appropriate uses. 
In skilful hands it will preclude tbe demand for the perforator or the crotchet, 
except in very rare cases ; and in these terrible cases, truly of life and death, 
the operator ought not to be satisfied with instruments which are but ill-con- 
trived succedanea. 

I am aware that the first impression of some persons, upon looking at the 
illustrations, will be, that the instrument is too straight, that the pelvic curva- 
ture ought to be continued into the shanks. If the whole operation, or the 
most difficult and important part of it, consisted in passing the blades above 
the superior strait, narrow blades, with a curve of a wider sweep, like those of 
Professor Siebold, slipping in probably with rather more facility, would be 
preferable. But as those here represented can be passed above the superior 
strait with facility, it seems to me that what I have already said upon the 
importance, in many cases, of having the pivot in nearly a direct line between 
the handles and the fenestra, furnishes a valid reason for adopting a model not 
differing essentially from that here presented. 

Others may object, that unskilful and incautious persons will be tempted 
to carelessness in applying such a forceps, and to avail themselves of the free 
motion of its lock unnecessarily. Professors of obstetrics, if they deign to 
notice it, ought to give their pupils the proper directions and precautions in 
the use of this instrument, as they do in that of others. Some persons are, 
indeed, so unhandy in the use of any instrument or tool, that all the profess- 
ors in the land cannot give them such tact and dexterity, that they ought to 
be allowed to approach the puerperal bed. Should this instrument happen to 
fall into such hands, the danger to either mother or child would probably be 
much less than from the use of powerful, unaccommodating forceps, misapplied 
by such hands. 

Others may object that it is an innovation, a gim-crack novelty — for they 

70 Burnett's Histological Researches. [July 

are the conservatives, scrupulously maintaining the ancient landmarks. It 
differs from the one extolled by their venerated preceptor, the one to which 
they have been accustomed, and in the use of which experience has given 
them expertness. Long companionship produces partiality, and perhaps some 
little modification of their own may have given them the feelings of paternity. 
It has answered their purpose, for with it they have accomplished delivery 
safely ; and if, in some instances, they have wounded the integuments or frac- 
tured the cranium ; or if they have been compelled to resort to the perfora- 
tor, in cases where the forceps was indicated, they will console themselves 
with the reflection that it was an inevitable destiny — a fault of nature, and 
not a defect of art. 

In conclusion, I must observe that I am by no means pertinacious for the 
precise model of the instrument presented in the illustration; for it is not im- 
probable that experience may suggest modifications of it, which will improve 
its adaptability, and yet retain its essential principles. All I ask is, a careful 
and candid examination of those principles. 

Art. VII. — Histological Researches on the Development, Nature, and Function 
of Epithelial Structures. By W. J. Burnett, M. D. (Bead before the 
Boston Society for Natural History, Aug. 1, 1849.) 

The study of epithelial and epidermic structures was pursued most faith- 
fully and successfully in the years 1835-36, by Purkinje, Valentin, and 
Henle. To these investigators and able physiologists belong the refinement 
of the quite crude notions of these structures entertained by the earlier 
anatomists. This portion of general and minute anatomy received at that 
time, both by these men and their coadjutors, such a thorough analysis, that 
later inquirers have been content to follow in their paths without entering 
upon the many portions of this field of inquiry hitherto unexplored. 
• It is for this reason that we find in the general works and text-books of 
anatomy and physiology a succinct account of these tissues taken for the most 
part from the writings of these men. Their higher relations, however, to all 
or nearly all the more important functions of life have been, although the 
most interesting, but lightly discussed; and the paucity of thorough observa- 
tions in this direction must have been felt by every student of minute anatomy. 

From continual microscopical examinations and investigations of the vari- 
ous tissues of the economy, the importance of this structure has been repeat- 
edly impressed upon my mind. In common circumstances, the difficulties of 
such investigations are not easily met ; and it was from the fine opportunity 
afforded me by the presence in this city of epidemic cholera, that I was in- 
duced to follow out these inquiries. 

1850.] Burnett's Histological Researches. 71 

While making a somewhat extended series of microscopical analyses of the 
well-known rice-water dejections from patients affected with this disease, in 
order to arrive at either positive or negative results as to the importance of 
such analyses towards determining its cause, the immense quantities of epithe- 
lial structure continually in the field of observation was a pressing invitation 
to examine carefully its structure. 

This epithelium, the immense quantities of which give the dull-white opacity 
or "rice-water" character to these dejections, appears to he removed still 
attached to the basement membrane, in quite sizeable flakes, and in a condition 
far more delicate and uninjured than could have been brought about by the 
gentlest and most accomplished manipulations of the anatomist. 

Inquiries of this kind are of importance in two points of view. 1st. As 
elucidating the development and nature of this tissue, considered as a struc- 
ture of the animal economy. 2d. As illustrating, in a very definite manner, 
the origin, development, and real nature of cells considered as the primordia 
of all organized forms. 

I need not here point out what others before me have done, either upon 
this structure or upon the general doctrines of cells involved in the following 
pages, but shall take up the subject as it was investigated, authors being 
credited as known portions of it pass in review.* 

Epithelial structure, it matters not where it is found, is always essentially 
the same — and, in brief, is composed of individual, non-organizable cells, 
attached to a primary membrane, which last is itself attached to the tissue to 
which the epithelium belongs. 

This arrangement is quite prominent and easily seen upon the tubes of the 
body, and although not capable of an equally satisfactory demonstration, yet 
most probably the epidermis (the external continuation of this epithelium) is 
thus arranged upon a primary or basement membrane. The localities of epi- 
thelium are summarily the following, viz., the skin ; the alimentary canal, 
and its appendices, even to their minutest ramifications of tubes ; serous and 
synovial cavities; the heart and blood-vessels; the lymphatic glands, and 
those connected with the reproductive system (mammae and testes). 

* For the principal works on this subject, the reader is especially referred to the 
following : — 

Purkwje et Valentin — "De Phenomeno Generali et Fundamentali Motus Vibratorii 
continui in Membranis Animalium." Breslau, 1835. 

Schwann — Mikrokopische Untersuch. 1839: p. 85. 

Miiller — " Elements of Physiology." Translated by Baly : vol. ii. 

Henle— k 'Traite D'Anatomie Generale." Trad, par Jourdan. Paris, 1843: vol. i. p. 225. 

Valentin — Art. "Flimmerbewegung," in Wagner's Handworterbuch der Physiologie. 

Also the writings of Gerber, Carpenter, Todd and Bowman, and many others, scattered 
in various journals. 

Although some of my own observations are but repetitions of some recorded by these 
men, yet that the subject may be the more complete, and as I was then ignorant of them, 
I have thought best to record the whole. 

72 Burnett's Histological Researches. [July 

We see by this that epithelium exists wherever there is mucous membrane ; 
hut that it is also found where the former is not. 

It may be divided into three varieties, known for some time as the — 1st, 
pavement; 2d, the cylinder; and 3d, the ciliated epithelium. Viewing an 
epithelial cell as the representative of a species (and it has under all circum- 
stances the same characteristics, sufficient to entitle it to the name, and cells 
have their types as well as the higher organizations), the two second forms 
may be considered as mere varieties or transitionary forms of the first, or 
pavement, since they arise from it, and only progress to little farther and 
varied stages of development. 

As I have had the pleasure of being able to study all of these forms, as to 
their origin, development, and their assumption of the peculiarities which 
distinguish them as varieties, I shall take up each separately. 

1st. Pavement Epithelium. — This is the simplest form of this structure, 
and lines the most delicate surfaces belonging to the economy, besides forming 
the epidermis. It is found upon serous and synovial surfaces, lines delicate 
tubes, and covers some portion of the alimentary canal. In fact, it occupies 
all secreting surfaces. This epithelium consists of spheroid cells, of a size 
varying from 3 oVo^ n *° 2 oVo^ n °^ an mcn m diameter ', each have a round- 
ish, oval nucleus, which is a hollow sphere, and inside of which is sometimes 
a nucleolus. Situated upon the primary membrane, from which they appear 
to grow, they seem bound together by a most delicate tissue. From such 
contiguity, and from equilateral pressure, hexagonal and other forms are 

The early formative stages of all epithelium are the same, and as the tes- 
selated or pavement variety is of all the simplest, I shall, of course, in de- 
scribing its origin, give at the same time the different phases of early growth 
through which the other two forms likewise pass. 

The earliest stage of development that I have been able to see in this 
structure, is a spheroid " bud" standing off the primary membrane. This is 
the embryo-cell, and may or may not contain a nucleus. 

By the function of endosmosis its nutrition goes on, and it gradually en- 
larges, still preserving its spheroid shape, and its attachment to the membrane. 

All this time, during which the cell is arriving at its adult and perfect state, 
and just ready to discharge its function as an individual cell, the nucleus is 
increasing and assuming more and more the characters of its parent. From 
a mere dark point in the centre of the parent-cell, it enlarges by endogenous 
growth, and soon is a hollow vesicle like its parent, but is filled with a granu- 
lar fluid. But the contents, before being granular, are clear and hyaline ; so 
that the first is the hyaline stage, and the second the granular stage. From 
this granular liquid, and making the third stage, a nucleolus is formed, but 
by a method which I was unable positively to determine. 

Sometimes two nucleoli are formed in one nucleus; and such phenomenon 
cannot, I am well assured, be considered accidental, but as having a positive 
relation with the reproduction of cells, as will soon be made evident. 

1850.] Burnett's Histological Researches. 73 

Most commonly, by the time this nucleolus has appeared as a vesicle, the 
parent-cell disappears ; so that the occurrence of nucleolated cells in the field 
of observation is not very frequent. Henle affirms that he has never or quite 
rarely seen nucleolated cells of epithelium, except in the lower vertebrata. 

The parent-cell bursting and discharging its contents, and these contents 
form the various secretions — the nucleus, being generally unattached to the 
cell- wall, is set free — and thus freed, it is a true nucleated cell. Whether it 
then attaches itself to the primary membrane, and then follows the same 
course as did its parent, is a point which I have been unable to determine. 
A new cell-bud immediately succeeds the place of the old one just passed 
away, and passes through the same phases. There is, therefore, a continual 
death and reproduction of cells, each of which has an individual existence like 
any of the compound organizations, and which, having completed, they die. 
The aggregate of these existences, in certain localities, constitutes, in most 
cases, a certain function in the economy. 

For the sake of conciseness and future reference, we will divide the life of 
these cells into the following well-marked epochs : — 

1st. A cell-bud as a hollow sphere, containing a clear liquid. 

2d. The clear liquid of this " bud" has a nucleus as a dark point. 

3d. This nucleus is a vesicle having a clear hyaline liquid. 

4th. The original cell still larger, the nucleus having a granular liquid. 

bth. An adult cell, whose nucleus has a nucleolus as a point. 

$th. Death of parent cell, with a discharge or retention of the nucleus. 

Such constitutes the whole biography of cells of epithelium, under most cir- 
cumstances, and as they are commonly observed ; and it will be seen that the 
general outline corresponds with that of other cells as already observed. The 
peculiarities here, however, as well as others quite as important connected with 
their reproduction, deserve our special attention sufficient for another and 
future separate section. 

Cylinder Epithelium. — This, as its name implies, is composed of cells of a 
cylinder-like shape, though as to exact resemblance, being more like a cone 
reverted. These cells are attached to the primary membrane by their small 
or caudate extremity, their broad or vase-like portion floating free. This free 
extremity is sometimes convex or concave, and sometimes truncate. This 
form is found, as far as I am aware, upon the mucous membrane alone ; and 
from my own observations, is rarely seen except upon those of the alimentary 
canal of the vertebrata. It appears to be only the tesselated form modified by a 
further development ;* for like that form, it arises from a primary membrane 
in the shape of small spheroid cells, nucleated, &c. These increase to a certain 
size, and then begin to gradually elongate, and this elongation taking place at 

* It would appear to be a law among cells of an organizable capacity, or as indivi- 
duals by themselves, that the more tbey depart from their true spheroid cellular cha- 
racter, and assume other shapes, the higher may be considered their development. 

74 Burnett's Histological Researches. [July 

the expense of that portion attached to the membrane, it necessarily becomes 

The length of this caudate portion varies much : thus, upon the mucous 
membrane of the digestive tube the cells are simply pyriform, while- those 
from the bladder have, as may easily be seen, often a tail three or four times 
the length of the cell proper.* The nucleus and nucleolus of this variety in 
no way differ from those of the pavement or simplest form just described. 
As for its more special localities, it would be rather difficult to define them 
accurately. It occupies mucous membranes only, and generally those which 
act as large aperient ducts. Rarely is it found investing parts, having the 
functions of peculiar secretions, and it is in this way that it differs physiologi- 
cally from the pavement form. 

Ciliated Epithelium. — This is the third and last variety — and, aside from the 
phenomena which invest it in common with the other forms with great 
interest, it has others of the most curious and remarkable in physiology. 
We will therefore give it a detailed and special attention. 

Its marked anatomical feature is that one or more of the surfaces of the cells 
(which may be of a pavement or cylinder form) are covered and studded with 
digitoid elongations of the cell-sac, known better, perhaps, by the name of 
cilia. Henle represents the ciliated epithelium as belonging to the cylinder 
form only ; but my own observations have shown that, although generally 
of the cylinder form, it may often be found, especially when taken from the 
human mouth, or from those of the Batrachians, to be of the pavement 
variety. Its origin and simple cell characteristics need not detain us ; for, 
previous to the formation of the cilia, it has no distinguishing traits. 

The production of these cilia I have had the good fortune to observe — the 
observations being made upon the epithelium of some of the Batrachians. 

It takes place in the following manner : The cells having reached the adult 
age (for I have seen no young cells with cilia), there appears upon its free 
extremity a vesicular projection, which, when fully formed, rests like a cap 
upon its surface. 

This then splits up into fasciculi, which, being sub-divided, form the true 
cilia, f 

The cilia are therefore situated upon the extremity alone of the cell, if the 
cell be of a cylinder shape, and upon a certain segment if the cell be spheroid. 

Generally speaking, they stud thickly the surface, but I am quite positive 

* The extreme caudate character of many of the epithelial cells of the bladder is a 
fact worth the remembering, in a pathological as well as physiological point of view. 
For with those not accustomed to observations of this kind, the appearance of such cells 
in urine would be a matter of much surprise. At first they might seem to be sperma- 
tozoa, then again the caudate cells of encephaloid carcinoma. 

f Kolliker, in a work published in 1840, has noticed, as I have since found, a similar 
mode of their production in the cells of the ovid uct of Planorbius corneus. — Vid. Beitraege 
Zur Kenntniss der Saamen fluessigkeit wirbelloser Thiere. 1 ' p. 33. 

1850.] Burnett's Histological Researches, 75 

in affirming that in some few instances I have seen them situated coronet-like 
around the edge, the middle portion being unoccupied. In such cases no new- 
mode of formation is involved, since such a disposition would ensue, if the 
parent vesicle had become concave before the division into fasciculi. 

The structure of these cilia has been much commented upon by Ehrenberg, 
Purkinje and Valentin, and, as far as concerns those of epithelial cells, has 
had an undue share of importance. They speak of them as being bulbous at 
their lower extremity; but although my own observations on this point have 
not been sufficient to afford me an opinion, yet their very mode of formation 
seems to argue against such view, and indicate that they differ in no way from 
the cell- wall on which they stand. 

Oiliary Motion. — The most interesting and the most difficult part of our sub- 
ject appear together ; and one cannot leave this field of inquiry without 
having many new views of animal powers and forces. The motion of entire 
cells cannot fail to excite our attention, but the movement of appendices to 
cells, when a certain and definite system of motions is performed, is one of the 
most interesting points in physiology. 

We are here at once brought back to our simplest ideas of motion, and 
where the fact does not suggest a complication, as in the higher forms, but 
where the relations of the body or bodies to space is most simple, because the 
power acts most probably in a direct manner. It is on this account that I 
shall treat this portion of our subject with more than ordinary detail. 

The cilia of epithelial cells seem to have two kinds of motion only. 1st. A 
moving or fanning motion, which when slow is very uniform ; but when 
rapid, assumes a kind of dancing character. This is the most common move- 
ment seen. 2d. A twirling rotatory motion of the lower portions of the cilia, 
being infundibuliform. Of whichever of these the motions may be, they are 
always uniform throughout the same cell ; thus indicating that the cause acts 
equally throughout. 

We know as yet really nothing about the essential nature and cause of 
animal motion. We may divide and subdivide the powers by which it is 
expressed in the higher forms, but inevitably fall upon the last material mechan- 
ism through which it is produced, and can go no further. 

The ideas of muscular or an allied tissue and those of animal motion have 
appeared almost inseparable in physiology; and this because animal actions 
have always, or nearly always, been traced to such tissue ; and where, in some 
of the lower forms, its direct demonstration could not be made, its presence 
has been assumed in virtue of necessity. But it seems to have been forgotten 
that, as in the external world, the same results follow from the employment 
of dissimilar means, or vice versa, so in the domain of physiology, we often 
have the same function performed by dissimilar organs, and vice versd* 
We can, therefore, consistently with analogy, look for real motion from other 

* Strauss Durckheim. 

76 Burnett's Histological Researches. [July 

than muscular tissues, and I have no doubt that further and more accurate 
researches into the infusorial world will lead us to adopt views of this kind. 

This digression may serve as a fitting prologue to the following and most 
difficult part of our subject. 

Ordinarily, ciliary motion may easily be observed, but few are aware of the 
difficulties which prevent a true solution of the problem of its cause. The 
first step in an inquiry of this kind is to ascertain how far we can consider 
these muscular movements. 

It is well known that Ehrenberg has affirmed to have seen bulbous roots of 
the cilia of some of the infusoria, and thinks that these bulbs contained the 
small muscles by which these bodies were moved. But although bulbous cilia 
may have been seen, yet the assertion of the muscular contents is quite 
gratuitous, as it is based upon the idea that their motion must be of muscular 

Purkinje and Valentin afterwards thought that the cilia of epithelial cells 
are bulbous ; but as would be but justice to the optics of the time at 
which their investigations were made, they are far from being positive on this 
point. The grounds for not adopting the opinion of their muscular cause 
become more numerous and positive as the inquiry proceeds. 

In the first place, the relative size of the cilia to that of the muscle makes 
it inadmissible, for in the vertebrate, the cilia of cells are very much smaller 
than the smallest fibrillse of muscular tissue ; so that, if the moving tissue 
be muscular, it is different from that of the body generally. To the same 
effect is also argued by the primitive formation of muscular fibrillse — being 
chains of cells, nearly as large as those of ephithelium themselves. 

The followers of Ehrenberg would perhaps affirm that these are no objec- 
tions, since that great microscopist has mapped out whole systems of internal 
organs in animals equally as small. Be this as it may with Ehrenherg, other 
observers upon this subject have arrived at the conclusion that the difficulties of 
observing clearly and accurately matters so extremely minute, with the micro- 
scope, must ever cause an unfortunate obscurity to exist upon this and all 
kindred subjects. 

There are, however, other objections of more determinate value. 

The motion of the cilia belongs to the cell alone, and has no connection 
with the system to which the latter is attached. This is at once demonstrated 
by their long-continued movements, when the cells are swimming free in the 
field of view. We know as yet no muscular tissue which has not nerves, 
and one cannot for a moment suppose that these cells have a nervous tissue. 

Some experiments instituted by me upon the epithelium of some of the 
Batrachians have all tended towards the same point. 

I killed a frog, and wrapping it in a damp cloth, laid it aside for sixteen 
hours. At the end of that time, I found the cilia of the epithelial cells of the 
throat in active motion. At the end of forty-eight hours, the motion had not 
ceased, although the animal had so far decomposed as to be offensive. 

1850.] Burnett's Histological Researches. 77 

These experiments were repeated with the same result, and in one instance 
I think the motion was continued for a considerably longer time. At least it 
appeared that the motion could he kept up long after the animal, and even 
the primary membrane, had begun to decompose; and that they always 
were present until the death and disruption of the cell to which they belong. 
And from this it would appear that they are inseparably connected with the 
life and functions of the cell. 

The effect of physical agents upon these movements should not here be 

Ether, as is now well known from a modern discovery, when inhaled and 
distributed throughout the system, first paralyzes the muscles of animal, and 
lastly those of organic life ; and when this last occurs, death of course follows. 

In my own experiments with this agent upon some of the lower animals, 
I have found that if the etherization be sudden and fatal, the post-mortem 
muscular irritability of the animal is either very much impaired or entirely 
destroyed; in other words, the shock which the nervous system thereby 
receives is so great as to destroy essentially most of its inherent energy and 
susceptibility to the action of external agents. 

With some frogs, which I suddenly and fatally etherized — and whose organic 
life seemed thereby so completely destroyed that irritation would not produce 
any muscular excitation — I found that the motion of the cilia of the epithelial 
cells upon their mucous membrane was not in the least impaired by such ex- 
periment, and their duration was equally as long as those of cells coming 
from animals otherwise killed. 

The narcotico-acrid poisons seem to have as little effect; for with an animal 
which I destroyed with strong hydrocyanic acid, there appeared no change in 
the movements of the cilia.* 

It would be supposed that the effect of electricity upon these bodies would 
be productive of results tending to throw some light upon the nature of the 
moving power, since we are now so well acquainted with its usual effect upon 
all known contractile tissues. 

With a view to learn definitely the effect of this agent in this respect, I 
made the following experiments : — 

A frog was taken, and being rendered insensible by ether, one needle was 
inserted into the brain and another into the lower portion of the spinal cord. 
A powerful electro-magnetic shock was then passed through the animal, the 
wire touching the two points. The animal was instantly killed. An imme- 
diate examination of the epithelium upon the mucous membrane showed the 
motion of the cilia to be unaffected. 

Not satisfied with this experiment, I took another frog ; and, after etheri- 
zation, inserted two needles opposite each other, just under the mucous mem- 

* Purkinje and Valentin speak of having tried strychnia with the same effect. 

No. XXXIX.— July, 1850. 6 

78 Burnett's Histological Researches. [July 

brane of the pharynx; a powerful shock was then given; an immediate 
examination of the cilia showed them in active motion. 

To make the matter still more certain, I took another frog, and dissected up 
a quadrilateral strip of the mucous membrane of the pharynx. The needles 
being insulated from the rest of the animal were inserted oppositely. A 
charge was then sent through it, but the motions of the cilia were not affected. 
Lastly, I took another frog and removed from its mouth a portion of the 
epithelial layer. This was placed upon a plate of glass in water, and then 
put under the microscope, and, while I was observing the motions of the cilia, 
an assistant applied the two poles of an electro-galvanic battery at the opposite 
ends of the glass in the water. A charge was then transmitted, but all the 
while the motions of the cilia were not in the least perceptibly affected. 
These various experiments were repeated, but with the same results ; and in 
all of them great care was taken that no means of delusion should be intro- 

It would therefore appear from the above, that whatever may be the moving 
power of these cilia, their motion, unlike that produced by all other contrac- 
tile tissues with which we are acquainted, is unaffected by electrical agents. 

We again revert to the question, What is the cause of ciliary motion? Let 
us sum up the arguments which go for its exclusion from the muscular domain. 
1st. It appears that the power belongs to the cell, considered as an indi- 
vidual organism. 

2c?. That the motion is capable of continuing until the death of the cell, it 
matters not what changes occur in the animal body to which they belong. 

3d. That the motion is unaffected by any method by which the animal to 
which they belong may die. 

Ath. That electrical forces, to which the other contractile tissues have so 
great a susceptibility, do not in the least affect the continuance or variety of 
their motions. 

5th. That all acids which, when directly applied, impinge upon the tissue 
of the cells, destroy rapidly the movements of their cilia. 

Now, if we bear in mind these results, and at the same time the fact that 
as yet no muscular structure has been distinctly seen in these bodies, and 
that they are known to exist on the ova of polypes, which in one sense are 
structureless — these points being considered, one is perhaps justified in dis- 
senting from the opinion of Prof. Ehrenberg, that they are the result of 
muscular tissue. 

With such a negative view, I am quite unwilliDg to offer any positive 
opinion, more especially when I reflect how little we know concerning the 
cause of motions in the lower and infusorial world. 

Voluntary motion has been considered the peculiar feature of the animal 
world, and the distinguishing characteristic which separates it from the vege- 
table kingdom. But the whole matter is now just as vague as before this 
feature was introduced. For it now remains to be decided what constitutes 
voluntary motion — a question not yet ripe for decision. 

1850.] Burnett's Histological Researches. 79 

If we consider that among the higher animals, a voluntary motion consists 
mainly, 1st. In a sensation being perceived ; and 2d, a consequent action ; 
then certainly we cannot regard the " adapting" motions of the members of 
the lowest animal world, scarce escaped from the characteristics of maternal 
cells, as voluntary, when their organization admits of none of the usual 
sentient organs. 

Take any species of the class Rotatoria of Ehrenberg, and observe its 
motions beneath a microscope ; they are not molecular, nor oscillatory, but have 
a certain indistinct adaptation to existing circumstances. Such motions are 
wrongly termed voluntary, and although they seem somewhat different 
from those of the Oscillatoria of the vegetable world, yet most probably 
belong to the same category. To the same belong the movements of sper- 
matic particles which are only epithelial cells of a peculiar animal character," 
and fulfilling a higher function than that usually allotted to these cells. The 
spermatic particles exhibit the same phenomena as to motion as do the 
cilia of the epithelial cells, under the same experiments above instituted ; and 
as a variety of epithelial structure, it would have claimed our special attention 
were it not too long, and already the subject for a future discussion. 

Exactly as the movements of the cilia cease with the life of the epithelial 
cell, so do the motions of spermatic particles cease with their vitality. 

All these epithelial motions have not the least claim to that of a voluntary 
character, although often remittent in their course. All that the foregoing in- 
quiries and experiments have shown, are only negative in character j and for 
positive knowledge of the cause of ciliary motion, we probably shall never 
have it until we know more extensively and clearly the laws of vitality as 
manifested in primordial organic forms. However this may be, the following 
conclusions can, I think, be justly drawn from the foregoing remarks. 

1st. If the movements of the cilia of epithelial cells are due to a contractile 
tissue, at their lower portion, this tissue is unlike any other contractile 
tissue of the animal economy with which we are acquainted. 

2d. We have no reason to suppose this tissue to be muscular. 

3d. Because of the relative size of the nbrilise to that of the cilia, and of 
the absence of nerves. 

4:ih. Because also electrical agencies do not affect it. 

bth. We cannot consider this contractile tissue of the nature of that of the 

6^. Because the movements of the cilia are of a uniform and rhythmical 

1th. That these movements are inseparably connected with the life of the 
cell to which they belong, considered as an individual organism. 

8th. That these ciliary movements of epithelial cells are, in many respects, 

* This I am persuaded, from observations in this direction, which have of late quite 
closely engaged my attention, and which I shall expose at another time.. 

80 Burnett's Histological Researches. [July 

analogous, if not identical, with those of many of the infusoria, and also with 
those of the ova of polypi. 

9 th. That after a full consideration, one would be inclined to the opinion 
that ciliated epithelial cells (spermatic particles included), although belonging 
to the category of individual animal cells, differ widely from cells in general, 
and especially as exhibiting a higher form of vitality and function. 

Reproduction of Epithelial Cells.— While speaking in the foregoing pages 
of the growth of epithelium, I merely alluded to its reproduction by the usual 
endogenous cell method, viz., by nuclei growing into cells. It would have then 
been in order to have closed up all that which relates to this part of the subject \ 
but as it might obscure the description there given, and more especially as it 
seemed to demand a separate paragraph from peculiarities, I shall here take 
it up as a distinct portion. 

The earliest period at which we can observe, the future cell is a minute 
granule in a blastema. As to the origin of this, we know really nothing. 
Next, it is observed as a hollow vesicle, filled with clear fluid. Still further, 
this liquid is cloudy and granular. Next, the granular appearance has disap- 
peared and a solid nucleus is seen. All this while the parent cell is increasing, 
and at this period you have a nucleated cell. This nucleus goes through the 
same changes as its progenitor; and when it has a nucleus, we have a nucleolated 

It will immediately be seen that the mode of cell formation here indicated 
is quite different from that advanced by Schwann and Schleiden as to both 
animal and vegetable cells. It is important, therefore, on this very account, 
marking a more extensive mode of their production. But its great interest 
lies in another direction, as showing the real grounds of the identity of the 
character of a cell and that of an ovum.* An ovum, we know, is but an 
agglomeration of peculiar cells, for the highest end attainable by cells in the 
animal economy. Our simplest and most divested idea then of it, is a pecu- 
liar cell, and the changes here spoken of relate to the real value of this 

I have spoken of spermatic cells as being really epithelial cells. Now, 
between the true structure of an ovum and that of a cell there is no dividing 
line among the lower animals 3 and we can only decide the character of each 
by the products (ova or sperm) which each yields. In these cases, the ova 
are first cells upon a basement membrane of the ovarian tubes, and except for 
a few peculiarities, do not differ from the sperm cells originating in the same 
way. Ova are therefore originally but epithelial cells. It can therefore be 
no wonder that the formation of epithelial cells upon mucous membranes 
should thus so thoroughly agree with the formation of ova. 

Prof. Agassiz was the first, I think, to point out these changes as occurring 
in the ovum. This he did in the spring of 1848. 

* Vid. a paper on this subject, in proceedings Am. Associat. for Prom, of Science, 
1849, p. 261. 

1850.] Burnett's Histological Researches. 81 

His observations were made upon some of the inverbetrata, and upon the 
ova in their earliest stages , viz., as primitive oval cells. I need not here 
detail them ; the same phases are passed through exactly as those just indi- 
cated with epithelium. The peculiarities, then, of ova, or more properly 
of ovarian cells, lie not in their origin and mode of endogenous reproduction, 
but in their capacity for a destined and invariable end; viz., the reproduction 
of a new individual being. 

Another mode of the increase of these cells, and which I have repeatedly 
seen, must not here be omitted, especially as it is in corroboration of the above 

Out of the granular contents of the nucleus of a cell, there sometimes 
appear two nucleoli, instead of one. These are generally not near each 
other, but at opposite extremities of the nucleus, which is then oval. 

Soon after this, a slight sulcus is perceived at one of the poles of the trans- 
verse diameter of the nucleus. This deepening, the single nucleus becomes 
finally divided into two. So that from one nucleus of a parent cell, two 
nuclei may occur, each of which has its nucleolus. 

This mode of increase by lissuration corresponds exactly with the multipli- 
cation of the vitelline cells in the ovum. So that the mode of increase of the 
ovum cannot, as has heretofore been clone, be considered as peculiar, but as 
belonging to those same laws which seem inherent in all single, non-organiz- 
able cells. 

Functions of Epithelium. — The elaboration from the blood of the special 
fluid of the animal body, known properly by the name secretions (not excre- 
tions), is performed, it would appear, by the agency of cells; and our best 
anatomical as. well as physiological idea of the organs performing these func- 
tions, is a tissue or tissues, so arranged or disposed as to afford the largest 
surface for the existence of cells. These organs are glands proper, and the 
cells elaborating these secretions are epithelial cells. 

Saliva, milk, gastric juice, pancreatic fluid, bile, synovia, spermatic fluid, 
the secretions of the vascular sanguineous glands — as the thymus and thyroid 
glands and suprarenal capsules — the various secretions of serous cavities, all 
owe their peculiarities to the particular elaborative action of the cell walls 
through which they are obliged to pass before discharged. These are but the 
combined contents of ruptured epithelial cells. 

All these glands mentioned seem to be but a combination of the more 
solid or basement tissues for the support of what are called gland-cells, which 
completely line their internal surfaces. These gland-cells, have no distinctive 
characteristics from true epithelium. 

Many of the most difficult problems in physiology here come in and 
demand a consideration. One of which is, why that the epithelial cells of 
the mammary gland should secrete milk, while those of the cryptic glands of 
the stomach should secrete gastric juice. Such inquiries as these belong to 

82 Burnett's Histological Researches. [July 

the highest domain of the science, and cannot be solved until we shall have 
become more thoroughly acquainted than we now are with the powers and 
properties of animal cell-membranes, considered as to their two inherent and 
permanent capacities, endosmosis and exosmosis. 

It is thus that all our investigations upon cell-origin and development are 
continually shedding new light upon our vague ideas of what constitute the 
bases of all physiological science. 

From what we have just said, let us see what constitutes our simplest idea 
of secretion. A single cell receiving by endosmosis into its interior the 
serum of the blood, and by this means elaborating its special character. 

The function of eliminating effete matters from the blood does not most 
probably, I think, in the most marked instance we have in the body, belong 
to the agency of cells. This is the excretion of urine. Although we find the 
tabulae uriniferi lined even to their termination with epithelium, yet my 
own microscopical analysis of these organs has led me to infer that this ex- 
cretion must be viewed as a direct transudation from the blood into these tubes, 
in the Malpighian bodies. The functions of these last-named bodies can- 
not, I think, be otherwise satisfactorily explained in accordance with their 
anatomical relations. A considerable quantity of the water belonging to the 
urine may, perhaps, be derived from the escaped contents of ruptured epi- 
thelial cells lining the tubuli. But this watery fluid has probably no cha- 
racteristics, and is like that from the same source, bathing serous membranes. 
And all that which distinguishes the urine as such, belongs to the functions 
of the Malpighian bodies. This portion of our subject, however, needs a 
further analysis. 

The production of spermatic particles and of ova, although forming a part 
of this subject, as we have seen, cannot here be discussed. Their origin has 
been truly spoken of. But of themselves, they have important points and 
relations sufficient for a separate article. 

The importance of the epithelial structures in the animal economy, and the 
high relations which they sustain, have thus in the foregoing pages been im- 
perfectly delineated. 

The subject is far from being as yet exhausted, in a physiological point of 
view ; and as pathology is but an erratic physiology, so I am well assured 
that we can look at the former oftentimes for a fine elucidation of the true 
bearings of the latter, as far as relates to this tissue. But details of this cha- 
racter would scarcely belong to a purely physiological paper, and are there- 
fore in this place omitted. 

1850.] G-ayley on Cholera Asphyxia. 83 

Art. VIII. — On Cholera Asphyxia. By James F. G-ayley, M. D., of 


In a former number of this Journal (January, 1849), we discussed the 
etiology of intermittent and remittent fevers, and the following were our 

1st. That the lungs and the liver are the great decarbonizing organs of the 
body ) that their function being complementary, the activity of that function 
is always in an inverse ratio. 

2d. That, during winter, the lungs, from the part they perform in the gene- 
ration of animal heat, are the more active organ. On the other hand, in 
summer the liver is the more active. 

3d. That exposure to a low temperature repels the blood from the surface 
to the internal organs. If this exposure takes place in winter, the lungs being 
then the active organ, the brunt of the congestion falls on some part of the 
respiratory apparatus j hence we have catarrh, bronchitis, pleurisy and pneu- 
monia as the prevailing diseases. 

4th. But if this exposure takes place in summer, the liver being then in a 
state of stimulatioD, the force of the congestion falls on it. It becomes 
deranged, involving all those organs, more or less, whose blood has to pass 
through the liver to reach the heart. Hence we have bilious affections, as 
intermittents, remittents, dysentery, diarrhoea and cholera, as the prevailing 

5th. That the pulmonary diseases of winter and of cold climates, and the 
hepatic diseases of summer and of warm climates, are both produced by the 
same agents acting on the system. The different effects being solely owing 
to the different modifications of the agents, and the different conditions of the 
system when exposed to their influence \ and we might with as much truth 
say, that malaria was the cause of the one as of the other. 

The truth of the first proposition is evident from a reference to the function 
of the lungs and liver in the inferior orders of animals, and in the foetus in 
utero. In the reptilia, the blood from the inferior extremity and the viscera 
is decarbonized by the liver, while that from the upper extremity passes 
through the lungs. In the foetus, during the period of intra-uterine life, the 
liver does the whole of the decarbonizing labour, the lungs being inactive until 

But this process of decarbonization subserves two other very important 
purposes. In the lungs it is the source of animal heat ; in the liver it forms 
a fluid very important in the process of digestion. Accordingly, we find the 
normal temperature of air-breathing animals proportional to the amount of 
decarbonization performed by the lungs, and it is highest in those in which 
the whole of the blood passes through this organ, as in the mammalia and 
birds. The second proposition, therefore, follows immediately from the first, 

84 GUyley on Cholera Asphyxia. [July 

and may be considered a corrollary to it, viz., " that during winter, the lungs, 
from the part they perform in the generation of animal heat, are the more 
active organ. On the other hand, the liver is the more active in summer." 

The third proposition we will pass over as having no direct bearing on the 
subject under discussion. 

The fourth proposition we believe to be a very important one. It lies at 
the foundation of a proper understanding of all the diseases peculiar to the 
tropics, and to the warm season of temperate climates. In the article above 
alluded to, we endeavoured to follow it out in one direction, and to show how, 
under certain circumstances, it gives rise to intermittent and remittent fevers. 
Our object in the present article is to follow its workings in another direction, 
as the cause of cholera. 

The blood from the stomach, small and large intestines, has to pass through 
the liver to reach the heart. The condition of the circulation in the alimen- 
tary canal, therefore, depends very much on the condition of the circulation in 
the liver. We know that in plants, so long as healthy action is going on 
in the leaves, the fluid taken up by the roots flows onward regularly. But if 
we arrest this action by shutting out the light and modifying the state of 
the atmosphere, the circulation ceases, although it is propelled by a constant 
endosmotic force a tergo of from one to three atmospheres. If we let in the 
light, and restore the normal condition of the atmosphere, the circulation is 
renewed. So in the portal circulation. While the liver cells perform their 
functions properly, the blood moves on regularly through the capillaries 
of the stomach and bowels ; and these perform their functions in a healthy 
manner. But if any of the liver cells become deranged in such a manner that 
the normal function is not performed, we will have an effect produced in that 
portion of the portal circulation, which passes through them, similar to what 
we found in the circulation of the plant, when the function of the leaves was 
interfered with, viz., an arrest of the onward current. But the cceliac, 
mesenteric and hemorrhoidal arteries continue to pump in their usual quantity j 
" the supply is greater than the demand, and we have a glut in the market," 
viz., congestion. We have no anastamosing branches here through which 
this impeded blood can get around the liver, and thus reach the heart. Na- 
ture, however, has made provisions in the spleen for remedying this state of 
things for a time; so long as the spleen is able to accommodate the superfluous 
blood no bad results follow. But this state of things continuing, the spleen 
becomes at length filled; the engorgement extends to the splenic vein, 
thence to its tributary the inferior mesenteric ; and from the inferior mesen- 
teric to the vascular rete that lines the colon. Now, we know that whenever 
an obstruction to the venous circulation exists a f route, an exudation of the 
serum takes place through the walls of the distended vessels. If we apply 
a ligature around the arm, so as to impede the circulation towards the hearty 
all the parts beyond the ligature become osdematous from the exudation of 
the serum of the blood in the distended vessels into the cellular tissue. In 

1850.] Gayley on Cholera Asphyxia. 85 

the congested state of the vascular reteof the colon, this exudation takes place 
into the colon and gives lis diarrhoea. 

Such is the effect produced by the derangement of a portion of the liver 
cells. But the same agencies that produce an arrest of function of part of 
the organ may, under certain circumstances, act with such intensity as to 
arrest the function of the whole. And what will be the consequence ? A 
little reflection will tell us that the stomach, small and large intestines, will 
in a short time be in a state of extreme congestion. With this we will have 
increased sensibility (irritability), and an exosmose of the watery portion of 
the blood of the congested part into the stomach and bowels. As it passes, 
it will wash away the epithelial scales of the mucous membrane. The 
increased sensibility in the stomach produces vomiting j in the bowels, fre- 
quent stools j and these stools consist of the washed off epithelial scales mixed 
with the exuded serum, and present the appearance of rice water. In short, 
we have cholera asphyxia. 

The rapid arrest of the function of an organ of such importance as the liver, 
being the largest gland in the body, and the withdrawal of such a quantity 
of serum from the circulation, will produce changes in the character of the 
blood sufficient to account for the other symptoms met with in the disease. 

The state of the blood drawn in different stages of the disease, and post- 
mortem examinations, favour the view here advanced. A circular letter on 
the former subject was addressed by the Medical Board of the British Army 
to thirty medical officers stationed in the Madras Presidency. The disease 
prevailed at most of the military stations, during portions of the years 1819- 
20-21-22. "It was established by replies to this letter, as well as by an 
immense amount of concurrent evidence, that the blood of persons affected 
with cholera is of an unnaturally dark colour and thick consistence. Those 
appearances were very uniformly expressed by the terms dark, black, tarry 
in regard to colour ; and by thick, ropy, syrupy, semi-coagulated in respect 
to consistence. The change in the condition of the blood is likewise proved 
to be in the ratio of the disease ; the blood at the commencement seeming to 
be nearly or altogether natural, and more or less rapidly assuming a morbid 
state as the disease advanced." [Johnston on Tropical Climates, p, 355.) 
These are just the results that might be expected from the suspension of the 
function of the liver, and the consequent copious exudation of serum from the 
radicals of the vena portarum. 

The post-mortem examinations made by the English army surgeons, in the 
East Indies, give the following results—" In the abdominal cavity, the peri- 
toneal covering of the viscera present in general but little variation from the 
healthy standard ; occasionally, indeed, the morbid accumulation of blood in 
the vessels of the viscera, imparting an appearance of turgidity and blueness, 
is evident even on their exterior surface. We also find them bearing marks 
of inflammation, especially when the patient may have lingered long before 
death. In other cases, the whole tube has had a blanched appearance^ both 

86 Gayley on Cholera Asphyxia. [July 

internally and externally. . . . The liver has been commonly found to be 
gorged with blood, but not always. . . . The vessels of the mesentery have been 
very generally found to be uncommonly full of blood." (Op. cit. pp. 
359, 360. 

The Philadelphia College of Physicans appointed Drs. Jackson, Neill, II. 
H. Smith and Pepper, a committee to make post-mortem examinations of 
persons having died of cholera during its prevalence here last summer. 
The following is taken from their report. 

" 1. In the recent subject, the peritoneal coat, like all the serous membranes, 
was in all remarkably dry. The lubricating serosity was deficient in the 
serous membranes. 

"2. The epithelial layer of the intestinal mucous membrane was in all the 
specimens either entirely removed, or was detached, adhering loosely as a 
pulpy layer mixed with mucus or an albuminoid substance. 

" 3. Peyer's glands were developed to a greater or less extent in all the cases 

" 4. The solitary glands were also developed, and contained in the recent sub- 
ject a minute quantity of white substance. 

u 5. The villi were denuded of their covering, but unchanged in other re- 

" 6. The capillaries were entire, and manifested no departure from their 
normal state." 

In addition to the above, I learn from Dr. Neill, who conducted the inves- 
tigations, that the proper tissue of the liver was exanguious ) but that the large 
blood-vessels were gorged with blood. This was also the condition of all the 
large blood-vessels of the abdominal viscera. 

The engorgement of the large vessels of the intestines is given in both 
reports. The report of the English army surgeons is not clear in regard to 
the state of the liver. We know that the organ is composed of cells, which 
are the organ proper j the parenchymatous structure, which holds the cells — 
the little livers — together ; and the ramifications of the portal vein, which are 
only a mechanical arrangement to supply the cells with the fluid out of which 
to elaborate their proper secretion. In making post-mortems, these distinc- 
tions ought to be kept in view. In the report under consideration they were 
overlooked. Doctor Neill' s examinations were conducted with more discrimi- 
nation. He found the proper structure of the organ exanguious, but the blood- 
vessels supplying it gorged. The appearance of the capillaries observed by 
Dr. Neill admits of an easy explanation. We have seen above, the thickening 
of the blood that takes place during the progress of the disease, and that this 
change is proportional to the time the disease has existed, and its intensity. 
Before death, this exists to such a degree as to prevent the blood from enter- 
ing the capillaries. These, by virtue of the contractility of their walls, keep 
up a pressure on their contents, causing exudation, and this exudation con- 
tinues until they regain their normal size. That the blood is too thick to enter 

1850.] G-ayley on Cholera Asphyxia. 87 

the capillaries is evident, from the large vessels being gorged with it. The 
appearance presented by the serous membranes in those cases examined by Dr. 
Neill may be accounted for, by the intense congestion arresting the normal 
vital action of the part, and substituting one purely physical — the exudation 
into the cavity of the canal in the direction in which the least resistance is 
offered ; and this carries before it the epithelial layer of the mucous membrane, 
which gave the appearance presented by this membrane in the examinations. 
Without following out the principle any further in explaining the minutisc of 
the appearances presented, we will merely say that slight variations in the 
appearances presented after death do not militate against the theory here 
advanced. No agent, even if it acts uniformly, will produce precisely the 
same effects on all constitutions. But the cause of the disease here advocated 
(the arrest of the function of the liver) may exist in various degrees, from that 
of a few cells to the whole organ. In the details of the appearances presented 
after death, as well as the symptoms presented during life, we might expect a 
great variety. But there would be certain leading points in which they would 
all agree, u Fades non omnibus una, nee diver sa, sed talis decet esse sorores." 
And these points of agreement we have found in the gorged conditions of all 
the large blood-vessels of the portal system. 

The principles of treatment are obvious. The great desideratum is to un- 
lock the secretions of the liver by setting the cells to work. The question is 
how can this best be done ? The experience of the profession proves to us 
that nothing will do this so well as calomel. This must be our sheet-anchor 
in this terrible malady. My plan during the past summer was to give it in 
doses of from ten to twenty grains, at intervals varying from half an hour to 
two hours, mixed with a little sugar, and laid on the tongue, arid washed 
down with a little ice-water. I prefer this way of administering it, because it 
is rarely if ever thrown off. When given in pill or suspended in syrup, the 
irritability of stomach is such that it is apt to be ejected, before the material 
with which it is mixed can be dissolved by the liquors of the stomach ; but 
when given as above, it almost invariably remains, and acts like a charm in 
quieting the irritability of the stomach. In connection with this, I used 
sinapisms to the abdomen and extremities, and frictions with dry flannel, with 
a view of determining the blood to the surface and thus diminishing the supply 
to the viscera a tergo, while the calomel was creating a demand dfronte. This 
I kept up until the equilibrium of the circulation was restored. In regard to 
the dose, the quantity given above is only an approximation, as I seldom 
weighed it. My custom was to carry a vial of calomel always with me, so 
that when called to a case no time might be lost in sending for it. I poured 
out what I considered the dose required for the case before me, and adminis- 
tered it as detailed above. Some may object to what appears to be a whole- 
sale mode of giving calomel ; and well they might, if the mucous membrane 
of the stomach was in a normal state. But let it be remembered that it is 
being loosened and washed away by the constant serous exudation. This^ in 

88 GUyley on Cholera Asphyxia. [July 

connection with the fulness of the blood-vessels, will interfere with the process 
of absorption. It is probable, therefore, that only a portion, and in some cases 
a very small portion, is absorbed. These doses were given only until the vio- 
lence of the attack was broken. The number required to produce this effect 
varied from two to five. No bad consequences followed the use of the mer- 
cury. In one case slight ptyalism was produced, which yielded readily to 
the usual treatment. 

In some cases the convalescence was rapid. In others, there remained a 
state of system characterized by considerable thirst, jactitation, debility, and 
occasional watery yellowish stools. This yielded to small doses varying from 
one-fourth to one grain, three times a day. With several of these I tried an 
acidulated solution of quinia, but the stomach would not tolerate it. At a 
later period, however, when the function of t\\Q liver was re-established, as 
indicated by the improved stools and the disappearance of the thirst and 
jactitation, I found quinia to have a very happy effect. 

Such was my treatment of the disease during the past summer. Out of 
thirty-five cases, thirty-two recovered. Some of them were very bad cases. 
The three that died were beyond the reach of remedies when I was called. 
There was no pulse at the wrist, and sinapisms had no more effect than if 
applied to a dead person. In such a state of system, it is to be presumed that 
internal remedies would be as inert as external applications. This presump- 
tion is strengthened when we call to mind the tendency of the disease to 
destroy the mucous membranes. I never used opiates, camphor, brandy, 
capsicum, chloroform, or any of the thousand-and-one remedies recommended 
in this disease. Their multiplicity proves their inefficiency. The spasm and 
debility I looked upon as the effect of the state of things detailed above, 
and I considered that the best antispasmodic and the best stimulant which 
would start the cells of the liver to work. There is much sound philosophy 
in the aphorism of the father of medicine, " sanguis solvit spasma." If we 
get rid of the congestion and equalize the circulation, the spasm will dis- 

It affords me pleasure to append the following extract from the second 
annual report of the medical department of the Siam mission of the Presby- 
terian church, located at Bangkok, dated October 1st, 1849, and signed by 
Dr. House, detailing his treatment of cholera during its recent visitation to 
that city, as it agrees in a remarkable manner with my own. He says : — 

" With a thousand dying daily on his right hand and on his left, for weeks 
together, as may be imagined your missionary physician found abundant 
occupation, though the smitten people, palsied with fear, seemed to deem it 
useless to contend with death, and, at first, comparatively few bethought 
themselves of the foreign doctor, or appeared to think his or any art could 
avail. Nor, indeed, would it, save perhaps to check the complaint in its 
earliest and forming stage, had not a gracious Providence been pleased to 
direct his mind, perplexed and wavering, among the multiplicity of opposite 
remedies advised, to one simple course of treatment for the disease, which 

1850.] Leidy's Notice of certain Peculiar Bodies, in the Human Subject, 89 

soon evinced such results that no other was thought of or required. This 
course consisted in the administration of calomel in large doses ; a scruple or 
even forty grains being given at the outset, followed up at intervals of half an 
hour or an hour, with other scruple doses of the same remedy till relief was 
obtained. From one to four were generally required, though as many as 
seven have been given, and in one case two hundred and sixty grains were 
taken before the disease was subdued. Of course, unless the disease was most 
unequivocally marked, and admitted of no delay, milder means, such as mix- 
ture of laudanum and essence of peppermint, thirty drops each in a wineglass- 
ful of water, with external applications, were at first resorted to, and would 
often prove successful ; but these failing to arrest the symptoms, no time was 
lost in giving the grand remedy. 

"Your physician's experience with calomel, given as above stated, and 
before the pulse had ceased at the wrist, inclines him to look upon it almost as 
a specific for the cure of epidemic cholera. But two cases out of forty-five, 
to whom it was thus administered, disappointed his hopes ; all the rest re- 
covering, though many of them were not severely attacked. Nor did any 
apparently evil consequences seem to result from the exhibition of these 
immense doses of calomel, beyond a moderate salivation, and from this even 
several were exempt/' (Foreign Missionary, Feb. 1850.) 

In conclusion, I will take the liberty of saying that my treatment was the 
result of the opinion I had formed of the cause of the disease; and this opinion 
was reached by following out the principle expressed in proposition 4th, quoted 
at the beginning of this article. It was not a thing of accident, but a con- 
clusion arrived at by philosophical induction. 

Art. IX. — Notice of certain Peculiar Bodies observed in the Human Subject. 
By Joseph Leidy, M. D. [With five wood-cuts.] 

In the winter of 1845, while engaged dissecting a human subject, I observed, 
deposited in some of the tissues, certain bodies of a character totally different 
from any others known to me. Since then up to the present time, during the 
course of every winter, I have noticed the same kind of bodies in several white, 
more or less emaciated subjects, in the dissecting-room of the University 
of Pennsylvania. They are of a yellow-cream colour, very irregular in form, 
and vary in size from half a line up to one-fourth of an inch. The tissues 
in which they are found are the papillary layer of the dermis, the areolar tissue, 
and the voluntary muscles. 

In the papillary layer of the dermis, the course of deposit of the matter 
composing the bodies is in some measure determined by the lines of the 
papillae tactus, as is indicated in Figure 1, which represents one of these bodies 
deposited in a portion of the papillary layer of the dermis from the palm of 
the hand. Wherever the deposit exists, the papillae tactus are obliterated, 

90 Leidy's Notice of certain Peculiar Bodies in the Human Subject. [July 

In the areolar tissue, beneath the skin, or between the muscles, the bodies 
have no definite form or course, as seen in Figure 2. 

In the muscles, the direction of the bodies is to some degree determined 
by the course of the fibres, as is observed in Figures 3, 4, and 5 ; and where 
they exist the muscular substance is obliterated. 

When first noticed, I thought these bodies might be deposits or degenera- 
tions of the normal tissue into fat, or else entozoic cysts ; but upon closer 
examination they proved to be neither. 

Upon rupturing one of them — for they appear to be bound by a delicate, 
limitary film— a thick viscid matter exuded, which, submitted to the micro- 
scope, exhibited a seroid fluid containing numerous granules possessing a very 
great uniformity in size, measuring the l-14,285th of an inch, in diameter, 
and endowed with a very active molecular motion, amounting to a vibration 
equal to nearly four times their own diameter. 

The character of these bodies I am unable to solve. Are they connected 
with some form of disease ? and have they been before noticed upon the skin 
of certain patients ? 


Fig. 1 represents one of the peculiar bodies (a) deposited in the papillary layer of 
the dermis of the palm of the hand, magnified 20 diameters, b. Papillae tactus. 

Fig. 2. One of the peculiar bodies deposited in the areolar tissue, from beneath the 
skin of the wrist, magnified 10 diameters. 

Fig. 3. Do. from the sartorius muscle, magnified 7 diameters. 

Fig. 4. Do. from the biceps flexor cubiti muscle, magnified 9 diameters. 

Fig. 5. Outline of do., of a very irregular form, from the extensor carpi radialis longior 
muscle, magnified 10 diameters. 

Fig. 1. 

Fig. 2. 

1850.] Leidy's Notice of certain Peculiar Bodies in the Human Subject. 91 
Fig. 3. Fig. 4. 

Fig. 5. 

92 Kimball, Ligature of Internal Iliac Artery for Aneurism. [July 

Art. X. — Ligature of Internal Iliac Artery for Aneurism. By GlLMAN 
Kimball, M. D., of Lowell, Massachusetts. 

A. W. Wentworth, a machinist, 35 years of age, entered the Lowell Hos- 
pital November 15th, 1849. 

The account of his case, as given by himself at the time, is briefly as follows : 
As long ago as 1843, he first discovered a small tumour on the back part of 
his thigh ; hard, pulsating, with no pain, and causing neither inconvenience 
nor anxiety. 

It remained in this state till some time in 1848, when it began to increase 
in size, and trouble him somewhat in sitting. 

He now showed it to one or two physicians, who assured him it was nothing 
more than a fleshy tumour, that might be removed at any time with perfect 

In July, '49, while ill with dysentery, he fell under the care of Dr. Savory 
of this city; and during this illness, the tumour was for the first time intelli- 
gently examined, and its true character made known to the patient. It was 
now something larger than a goose-egg, and situated directly over the ischiatic 

The throbbing and peculiar souffle were present in a very marked degree, 
and severe pain was occasionally felt shooting down the back part of the 
thigh and into the calf of the leg. Indeed, every circumstance indicated 
that the tumour was aneurismal, and that it involved, probably, some branch 
of the internal iliac artery. 

The case was subsequently examined by other surgeons, who expressed the 
same views as to its nature; and suggested, as had been previously done, the 
ligaturing the internal iliac artery, as the only means of cure. 

Having now become acquainted with the importance as well as danger of 
his disease, and having also been fully apprised of the nature and risk of the 
only remedy that could be proposed for its cure, the patient resolved that he 
would resume his work, hoping that the fearful alternatives of an operation 
might at least be a long while postponed, if not avoided altogether. In this 
hope, however, he was disappointed. About the 10th of November, the pain 
in the thigh and leg increased, and a severe throbbiDg pain was felt for the 
first time in the lower part of the abdomen. 

His work now became irksome, so much so, that on the 14th of the same 
month he was obliged to' desist from labour altogether. 

Alarmed at the progress the disease was making, he looked to the opera- 
tion as his only hope, and resolved to take the hazard of it with as little delay 
as possible. With this view, he entered the hospital at once, and in four 
days after, Nov. 19th, the operation was performed. The mode of proceed- 
ing was as follows :— 

The patient having first been placed on a bed suitably prepared for the pur- 

1850.] Kimball, Ligature, of Internal Iliac Artery for Aneurism. 93 

pose ; and having been duly brought under the influence of chloroform, an 
incision six inches long was made immediately above, and to a certain extent, 
parallel to Poupart's ligament, beginning at a point just external to the 
spermatic cord, as it passes through the external ring running outward for the 
distance of three inches, then turning more directly upward and terminating 
on a line about midway between the anterior spinous of the ilium and the 
umbilicus. The abdominal muscles and iliac fascia were next cautiously 
divided, and at the lower end of the incision, the peritoneum being carefully 
raised brought to view the external iliac artery. From this point, the peri- 
toneum was still further raised from its pelvic connection by running the fore- 
finger of the left hand along the inner border of the psoas muscle, till it 
reached the promontory of the sacrum. 

The internal iliac was now readily traced in its descent from its point of 
bifurcation ; and while the forefinger of the left hand still rested upon it, a 
ligature was carried under it by means of a common aneurism needle, and the 
vessel secured by the aid of an assistant, about an inch from its origin. 

The tumour being now examined, was found to be somewhat diminished 
in size, and its pulsation to have entirely ceased. No accident or embarrass- 
ment of any kind occurred in any step of the operation. No vessel having 
been cut of sufficient size to require tying, the amount of blood lost was of 
course very inconsiderable, not more than two or three ounces. Finally, the 
wound was brought together with two or three sutures and adhesive straps, 
and covered with water dressings. 

Nov. 20th. Morning after the operation. — The night had been tolerably 
comfortable, but for the prolonged effects of chloroform which still produced 
more or less nausea. Pulse 108; considerable thirst. Abdomen not swollen, 
nor in the least tender, except in close neighbourhood of the incision. 

21st. Increased restlessness for the last twenty-four hours. This morning, 
however, more quiet, apparently from a dose of opium taken the evening 
before. Nausea somewhat abated; pulse 106; thirst the same. 7 P. M. 
Abdomen a little swollen and tender; occasionally hiccup. Still complains 
of the effects of chloroform. 

22c?. Night restless, though not without some sleep; pulse 112, full and 
soft; swelling of abdomen not increased; nausea, thirst and hiccup about the 
same. Bowels being constipated, ordered ten grains of calomel. 7 P. M. 
Continues restless ; rather more pain in abdomen ; cathartic not having ope- 
rated; ordered eight grains more calomel. 

23<i. Cathartic operated freely during the night, producing gome relief. 
An uncomfortable night, however, and without sleep. Abdomen less swollen 
and but slightly tender. Pulse 90, soft and full ; some nausea and hiccup 
still, but not so troublesome. The wound discharges pretty freely, some pus, 
but mostly the remains of blood which had been retained in the wound at the 
first dressing. 

2\th. Had a good night; slept most of the time ; pulse 90; no pain, and 
No. XXXIX.— July, 1850. 7 

94 Kimball, Ligature of Internal Iliac Artery for Aneurism. [July 

scarcely any tenderness of the abdomen ; discbarge more purulent. Asks for 

25th. Remains comfortable, but a good deal prostrated. Sutures have 
given way, and adhesive straps mostly detached by the abundant discharge. 
Still no soreness or swelling of abdomen. No indication of peritonitis j pulse 
86; complains of bad taste of mouth. Skin rather sallow. 

26th. Has been more comfortable for the last twenty-four hours than at 
any time since the operation. Appearance generally about the same. Com- 
plains, however, of soreness of the tumour, which appears slightly inflamed. 
Perspires freely during sleep. 

27th. Although appearing pretty well at present, the last twenty-four hours 
have been uncomfortable. Increased restlessness and fever. Pulse 110. 
CoDstant motion of left leg, drawing up and extending it constantly. Wound 
discharges very freely, its edges disposed to separate considerably. No appear- 
ance of adhesion or granulation in any part of it. Still no sign of peritonitis. 
Bowels moved regularly without medicine, for four days past. Urinates with- 
out pain or difficulty (which has not been the case for four days past). 
Ordered quinine in grain doses, every six hours. 7 P. M. A restless day; 
considerable fever; pulse 110; skin dry; thirst; breathing hurried; inclined 
to wander. Discontinued the quinine. 

2Sth. Does not seem so well as yesterday; night restless and sleepless; 
pulse 116; thirst; dry tongue. Skin hot and dry. 7 P.M. Appearance 
the same as in the morning. No movement of the bowels since day before 
yesterday. Ordered six grains blue pill. 

29th. Appears more comfortable; slept considerably through the night, 
and seems refreshed. Fever less; pulse 90. Complains of sore mouth and 
tongue, which upon examination proves to be covered with apthss. Wound 
discharges freely, but is not healing. Edges still disposed to separate and 
require to be brought together with considerable force with adhesive straps, 
and to be dressed as often as every six hours. Bowels not moved. Ordered 
another blue pill. 

30th. Appearances same as yesterday. 

Dec. 1st. Does not seem so well as yesterday. Had a severe chill in the 
night, followed with a good deal of fever. Slight cough and expectoration 
oi mucus tinged with blood. Bowels moved once. 

2c?. More comfortable. Slept pretty well, and says he is greatly refreshed, 
and feels quite well, but for the sore mouth. Had another chill sixteen hours 
after the first, but less severe, and followed by less fever. Sweats profusely 
during sleep. Cough and expectoration much diminished. 

3 d. No material change since yesterday. Has had two slight chills in the 
last twenty-four hours. Cough and expectoration almost entirely ceased. 

4-th. Called up in the night and found secondary hemorrhage. Blood still 
flowing freely from the whole extent of the wound. Called Dr. I. 0. Green 
in consultation, and considered the question of making a desperate attempt to 

1850.] Kimball, Ligature of Internal Iliac Artery for Aneurism. 95 

secure the primitive iliac artery. Decided that it was inexpedient. Hemor- 
rhage ceased after the loss of sixteen or twenty ounces of blood. 

The patient was frankly informed of his danger, still he quietly fell asleep 
and so remained for several hours. 

bth. Remarkably comfortable for the last twenty-four hours. No return 
of hemorrhage. Appearances generally the same as before it occurred. 

6th. Hemorrhage returned yesterday afternoon, thirty-six hours from the 
first attack. It soon ceased, however, and the night was passed very comfort- 
ably, till about 5 A.M., when the bleeding returned again with increased 
violence, and terminated the life of the patient at half-past eight, being the 
eighteenth day after the operation. 

Post-mortem six hours after death. — Upon removing the dressings, and clear- 
ing away the partially coagulated blood which had been pushed between the 
edges of the wound during the final hemorrhage, it was remarked, in the first 
place, that there was no appearance of healing, no granulations, the edges of 
the incision still remaining as distinctly defined as at the moment of the 
operation. At the bottom of the wound, particularly in the neighbourhood 
of the ligature, a large quantity of pus was found, mixed with blood, and ex- 
tending in various directions to a considerable distance under the peritoneum. 
The peritoneum itself, so much of it as had been torn up and exposed in the 
course of the operation, was very much thickened; and, upon being cut open, 
was found entirely free of all appearance of inflammation. 

A portion of the primitive, and so much of the internal iliac arteries and 
its branches as could be conveniently got at, including of course the part 
which had been ligatured, were now carefully removed and examined. The 
portion of the vessel between the ligature and the bifurcation being slit open, 
was found entirely empty. No trace of coagulum; no signs of inflammation 
on its inner surface. The part immediately embraced by the ligature had 
begun to give way, disclosing a very small aperture, sufficiently large, how- 
ever, to account for the fatal bleeding. 

The body was now turned upon the face, and the examination continued 
posteriorly. The tumour which had existed previously to the operation was 
observed to have entirely disappeared ; and comparing one side with the other, 
the only thing indicating the one affected was a slight discolouration over the 
left ischium. In cutting through this part, both the skin and subjacent parts 
were found somewhat condensed, and the muscular fibres paler than natural, 
and intermixed with an unusual quantity of cellular tissue; a condition sup- 
posed to have been induced by long continued pressure in sitting! Continu- 
ing the incision deeper down toward the supposed location of disease, it was 
soon found that no sac, or any other usual evidence of aneurism was to be 
found. Near to the point, however, where the gluteal artery makes its escape 
through the ischiatic notch, several sacculi or pocket like cavities were observed 
leading off in several directions, one of them upward under the edge of glu- 

96 Buckingham; Constitutional Irritation following Vaccination. [July 

teus minimus, and another behind the origin of the pyriformis muscle as it 
passes out of the pelvis. These cavities were perfectly defined, and lined by 
a thin membrane of condensed cellular tissue, over which was distributed a 
net-work of vessels. Still, the evidence of aneurism was too equivocal to be 
satisfactory; and it now became a matter of regret that this part of the ex- 
amination had not been made before the parts within the pelvis had been dis- 
turbed. But upon a further examination of the vessels which had already 
been removed from this region, a more satisfactory explanation was made out 
in the discovery of an aperture through the walls of the internal iliac artery, 
about two thirds of an inch below the point of ligature. 

This aperture was nearly the size of the calibre of the artery, and closed 
over by a thin coagulura loosely attached to its edges. Its exact relations to 
the ischiatic notch could not, of course, be determined, inasmuch as the parts 
surrounding it had been previously cut away with the vessels themselves. It 
seemed obvious, however, that the aperture in question, and the sacculi dis- 
covered outside the pelvic cavity, must have been in communication with each 
other, and thereby produced the tumour and its accompanying symptoms of 
aneurism ; but for reasons already given, this connection could not be demon- 
strated, and could only be considered as a matter of reasonable inference.- 

As regards the fatal result of the case, it would perhaps be scarcely worth 
while to refer to any particular circumstance which might possibly have had 
an influence in producing it. That the patient should finally die of hemor- 
rhage is nothing remarkable ; but that there should have been such an entire 
absence of all healing action, and especially that there should have existed such 
a positive destitution of fibrine as apparently to prevent the due formation of 
coagulum in the ligatured vessel, is not only remarkable, but quite unprece- 
dented in all similar instances on record. Without drawing any conclusions from 
these facts, they are nevertheless sufficiently important to be stated ; and more 
particularly since the question has already been raised in the minds of some, 
whether they were not connected with the large amount of chloroform inhaled 
during the operation. 

Lowell, March 10th, 1850. 

Art. XI. — Abstract of a Case of Constitutional Irritation following Vac- 
cination. By Chas. S. Buckingham, M. D. ; Physician to the Boston 
House of Industry. 

B , a farmer, twenty-five years of age, of previous robust health, re- 
siding in the western part of Massachusetts, till within a few weeks of his 
death. Father died of erysipelas many years ago. Mother and two brothers 
now living and well. He was the eldest child. Two brothers died in early 

1850.] Buckingham, Constitutional Irritation following Vaccination. 97 

childhood — cause unknown. I could learn after his death that there had 
been no sick animal on his farm; that he had, so far as was known, no com- 
munication with any such, nor had he any occasion to handle hides. He was 
vaccinated on Thursday, Aug. 28th, 1849, by a physician in his vicinity at 
the same time, and it was supposed with the same virus that a younger 
brother was vaccinated with. B. had been successfully vaccinated before ; 
the brother had not, and in his case the disease was taken and successfully 
terminated. In this case, the vesicle was described as abnormal. The patient 
was as well as usual till Aug. 31st, when slight febrile action took place, he 
having in the meantime come to Boston. 

Sept. 1st, he took an emetic, and on the 2d a cathartic dose. Both operated 
freely. I was first called to him at 9 P. M. Sept. 3d. 

Condition. — Complete anorexia ; great thirst ; headache ; sleeplessness ; 
pain in back; eyes and hearing normal; urine free; pulse 120, full and 
strong; decubitus dorsal. His late vaccination was not known at this time., 
Got a saline mixture, consisting principally of bicarbonate of soda and chlorate 
of potassa. 

4th. Febrile action less ; has pain in calf of right leg ; no tenderness, red- 
ness, swelling, or heat. R. — Tr. saponis et opii to part. 

bth. Pulse 90; appetite returned ; pain nearly gone. 

6th. Leg still painful ; appetite good ; secretions abundant ; omit medicine. 
R. — Aq. ammonise, spir. terebinth, aa partes. M. To the leg. 

9th. Pulse 84 ; appetite good. No sleep last night on account of the pain 
in the calf, and in the sole of right foot; has had a sinapism to the foot, with 
partial relief; no dejections for twenty-four hours; whole of right calf swol- 
len ; a circumscribed red spot one and a half inch below head of right fibula, 
covering about two square inches ; omit medicine and apply six leeches ; 
bleeding to be encouraged by poultices. R. — Magnesiae sulph. ^j, now. 
R. — Potassse chloratis Jij ; Acidi hydrochloric! Jss; Syr. aurant. cort. ^viij. 
M. 3J to ^ e taken every three hours. 

10th. Patient was seen, in consultation, by Br. Ii. Gr. Clark. Redness more 
diffused; leg much swollen, and cedeoiatous from knee to heel; pain confined 
to the spot of yesterday, which is, for the first time, tender; no headache or 
thirst; eyes and hearing normal ; neither delirium nor sighing; no appetite; 
tongue red at its tip, and in other parts covered with a thick creamy paste; 
pharynx the same; pulse 88, full. Repeat leeches ; omit medicine. R. — 
Quinise sulph. gr. j in solution every four hours. R.— Pulv. ipecac, eomp. 
gr. viij at bedtime. 

11th. Had headache after second dose of quinia, and it was omitted; slept 
well all night ; perspired freely ; no headache; no dejection ; pulse 100, full 
and soft; tongue, &c, as yesterday. A painful spot exists on the inside of 
the other calf; resume medicine of yesterday and nourishing diet. 

12th. Slept well ; quinia acted as before, and was omitted after second close ; 
less pain and swelling in right leg; pain with hard tumour in the spot on left 

98 Buckingham, Constitutional Irritation following Vaccination. [July 

leg ; no enlarged glands to be discovered in any part of either groin, nor in 
either lower extremity ; omit the quinia and resume the medicine of the 9th ; 
continue the Dover's powder gr. iv at night. Good diet, with cider or cham- 
pagne, P. R. N. 

loth, 9 A. M. Same as yesterday; pulse 100, full and soft; no dejection. 
Attention was called to a hard, red, circumscribed swelling on the left fore- 
arm, similar to the others; in examining which, found the remains of an 
irregular vaccination, of which I first learned the history, as above. Continue 
treatment; simple enema. 

12 J P. M. Dr. J. C. Warren saw him in consultation. He advised a con- 
tinuance of the present treatment, with the Tr. acid, sulph. for a drink. Pulv. 
ipecac, gr. x, now. 

To the 16th of September there was no apparent change, except a diminu- 
tion of the swelling of the right leg. Treatment was continued. 

lQth. Dr. W. J. Walker saw him, in consultation, at evening. At that 
time the swelling of the right leg was decidedly less. That of the left leg 
hard, red, and excessively tender. The right elbow was red and swollen. 
The right eye red, swollen, and painful about orbit; no conjunctival redness; 
tears trickling over face; pulse 120, full, soft, and dicrotic; respiration slow 
and distinct, with occasional sighing; no delirium; tongue perfectly steady, 
when protruded; face somewhat livid; no dejection for two days, except from 
enemata; has taken brandy and water to-day; omit medicine. R. — Hydrarg. 
submur. gr. ij ; Pulv. opii gr. |. M. Every two hours. Wine or brandy 

17th, Sh A. M. Slept well; pulse 112, of same character; respiration 16; 
no pain; no delirium, except on waking; tongue as before ; no dejection; 
takes no food ; swelling of legs less, otherwise as at last report ; may have 
ale, porter, or champagne. Continue medicine. 

7 P. M. Dr. Walker saw him again. Pulse 136, and of same character; 
respiration 16; occasionally sighing ; memory good; no fetor; has taken Oj 
each of champagne and ale. Continue treatment. 

18th. Had a good night ; pulse 112; respiration 16; nose much swollen, 
dusky red, and painful ; about a dozen papules, hard, red, and shot-like, scat- 
tered over forehead, face, back, and legs ; no glandular enlargement. 

12 M. A few more papules on abdomen ; the others are becoming pustular, 
and a few are umbilicated. 

10 P. M. Pulse 112, full, soft, and dicrotic; tongue dry and cleaner; no 
fetor; pustules larger, other swellings less; has had two small and offensive 
dejections. R. — Hydrarg. submur. gr. iij ; Opii gr. §. M. Every two hours. 

19th. 8£ A. M. Two dejections, with urine; tongue dry, black, and cracked; 
redness and swelling of whole upper face ; papules increasing in number, and 
pustules in size; a few of them umbilicated; no glandular enlargement. Hub 
in Uno\ hydrarg. jfss in axillse and groins. 

8 J P. M. Pulse 120; respiration 20, and noisy; sordes on teeth; no mer- 


1850.] Trugien's Case of Wound of Left Ventricle of Heart. 99 

curial fetor; tongue dry and cracked; takes brandy and water. Resume 
medicine of the 9th. 

20th, 10 A. M. Pulse 120, more firm, but not so full; respiration 32, 
laboured, no rales; numerous black, pasty dejections; took Oss of brandy in 
the night ; restless, and occasionally wandering ; easily roused, and speaks 
sensibly, but soon falls asleep again ; pustules increasing in size and number, 
some of them as large as good-sized peas ; knuckles of right hand swollen ; 
both sides of face red, swollen, and oedematous ; right leg of normal size, and 
appears well; left leg the same, with the exception of slight tenderness; swell- 
ing on left forearm soft and fluctuating ; no glandular enlargement, nor mark 
of absorbents. 

9 P.M. Constantly delirious; unable to drink; frequent involuntary de- 
jections, and urine; hands tremble; pulse 134, feeble; respiration 36, noisy 
and husky; sounds and impulse of heart normal; many of the pustules dry- 
ing ; scab of vaccination came off of arm ; erythema and osdema of scalp. 
Omit medicine. 

21st, 10 A. M. Delirious all night; takes nothing ; insensible; no dejec- 
tions; pulse 134, soft, and moderately full; respiration varies from 30 to 40, 
occasionally like that in hydrophobic paroxysm; heart's impulse strong; first 
sound loud, second sound scarcely perceptible. 

5 J P. M. Died. The body was removed early the next day. No autopsy 

Art. XII.— J. Case of Wound of the left Ventricle of the Heart. — Patient 
survived five days; — with remarks. By John W. H. Trtjgien, M. D., of 
Portsmouth, Va. 

On the night of March 18th, 1850, at about eight and a half o'clock, I was 
hastily summoned to visit a stout young negro man set. 21, who a few minutes 
previously, in a personal rencontre with another negro, had been stabbed in the 
chest. I found the man lying on the floor in a state of the most profound 
collapse. His body was as cold as a block of marble, and covered with 
profuse, cold, clammy sweat ; nor could the nicest touch of the finger, or th e 
ear applied over the region of the heart detect either radial or cardiac 
pulsation. The only indication of remaining animation was the occasional 
utterance of groans, and the application of the hands to the pit of the stomach, 
as if to relieve pain in that situation. On stripping open the shirt, a 
wound of half an inch in size was discovered in the left precordial region, 
equi-distant from the nipple and left edge of the sternum, and just over the 
costo-sternal cartilage of the fourth rib. There was little or no hemorrhage 
from the wound. On introducing the probe, it could be carried as far as the 

100 Trugien's Case of Wound of Left Ventricle of Heart. [July 

costal cartilage, but was then turned a little to the right when allowed to pursue 
its own course. My first impression on seeing the man was that the heart 
had been wounded, and that the case would terminate fatally. The arrest of 
the probe, however, and its deflection to the right caused me to come to an 
opposite conclusion. The extreme degree of collapse was attributed to other 
causes than the wound, viz., to the presence of crude indigestible food in the 
stomach, giving rise to intense pain there, or the impression of a blow or kick 
thereon, as suggested by my friend Dr. J. N. Schoolfield, who the next day 
visited the patient with me. The circumstance of his having vomited during 
the night a large quantity of crude ingesta, seemed to confirm this opinion. 
The result, however, will show that it was erroneous, and that the first impres- 
sion was correct. Notwithstanding the efforts made to induce reaction, he 
continued in the state above described for five or six hours. At last, how- 
ever, the forces of the system rallied, and by the following morning a mode- 
rate and equable reaction had taken place. No complaint was made of the 
wound, and there were no symptoms present to give rise to the supposition 
that the cavity of the chest or the heart had been penetrated. Respiration 
was normal, and the patient able to take a full inspiration without pain. 
There was, however, considerable tenderness and pain on pressure over the 
epigastrium, but which soon yielded to the application of a vesicant and the 
internal use of blue mass, opium and ipecac. The strictest maintenance of 
the horizontal position, together with the observance of perfect quietude were 
enjoined. This, together with the use of slop diet, constituted the treatment 
of the case. The wound was received on Monday night, and the patient con- 
tinued to improve until Saturday, warranting the prognosis which was given 
of a favourable termination. On the last named day, however, in positive 
disobedience of orders, he went out and used other improper exertions. At 
eight o'clock at night I was again sent for, and arrived only in time to see 
him die, which event took place in about five minutes after I reached him. 
He had been sitting up a few minutes previously, and conversing cheerfully 
when he suddenly complained of feeling very badly, sunk down from his chair, 
and expired. 

Autopsy, sixteen hours after death, by Dr. J. N. Schoolfield and the writer. 
The wound in the external integuments had completely healed. On removing 
the sternum, together with the costal cartilages, a large quantity of serous fluid 
escaped from the chest. A wound of two-thirds of an inch in extent was 
found traversing in an oblique direction, and completely perforating the fourth 
costo-sternal cartilage ; passing thence through the pericardium, it was traced 
into the substance of the right ventricle, a line or two to the right of the 
septum-ventriculosum. Its farther course was traced from right to left through 
the wall of the right ventricle, without, however, penetrating its cavity ; thence 
through the septum into the wall of the left ventricle, and through this into 
its cavity. Through the opening thus made, the blood had escaped into the 
pericardium, until it put a stop to the movements of the heart. About a pint 

1850.] Trugieu 's Case of Wound of Left Ventricle of Heart. 101 

and a half of blood, partly fluid and partly coagulated, was taken therefrom. 
The wound through the pericardium had completely cicatrized, as well also as 
that of the heart for two-thirds of its extent. The preparation now in my 
possession shows this very plainly. A circle of inflammation about the size 
of a quarter dollar is there seen to surround the wound of the heart. 

Remarks. — It has not been many years since all wounds of the heart were 
thought to be instantly and necessarily fatal. This, though not now the pre- 
vailing medical belief, is yet almost universally accredited by the laity. The 
numerous cases on record of protracted survivorship of wounds of the heart, 
some of them of the most severe character, as well as the case just detailed, 
show conclusively that death does not instantly ensue upon their reception. 
Indeed, from the researches of M. Ollivier upon this subject, it would appear 
that instantaneous death from wounds of this organ are of much less frequent 
occurrence than is generally supposed. Thus, out of twenty-nine cases of 
wounds of the heart collected by that gentleman, only two proved fatal within 
forty-eight hours, the others in from four to twenty-eight clays. 

Much time and labour have been expended in the collection of cases of pro- 
longed survivorship of wounds of this organ. Some of the cases reported are 
of such a character as to be almost incredible, but for the undoubted veracity 
of their authors. 

Dupuytren has reported several very remarkable cases ; and Dr. Beck, in 
his work on Medical Jurisprudence, has also brought together quite a num- 
ber. In the October number of the Am. Journal of the Medical Sciences, 
a case is recorded which was originally presented to the New York Patholo- 
gical Society, by Dr. W. S. Bowen, in which the patient survived a wound of 
the heart nine days. And in some cases collected by Dr. J. R. Coxe, and 
published in an early number of the same journal, life was in numerous 
instances prolonged for sixteen or seventeen days. Nay, the case is on record 
of a negro boy who survived a wound of the heart sixty-seven days, and was 
at one time able to walk about. (Reported by Dr. Ramsay, of Tennessee, in 
the Western Journal of Med. and Pliys. Sciences, vol. i. p. 329.) 

But, are wounds of the heart necessarily fatal ? Dr. Dorsey says " there is 
reason to believe that the heart has often been wounded without fatal conse- 
quences." And Baron Dupuytren gives it as his opinion that wounds of this 
organ are not necessarily fatal. Mr. Alfred Taylor, in his Medical Jurispru- 
dence says, " until some clear instances of recovery from penetrating wounds 
of the cavities are reported, the majority of practitioners will continue to look 
upon them as necessarily, although not immediately fatal. But, at least one 
case of recovery is on record (see Land. Med. Gaz,, vol. xvii, p. 82), and the 
case just reported, though terminating in death, has nothing about it to lead 
to the conclusion that recovery was impossible. On the contrary, the com- 
plete cicatrization of the wound through the pericardium, and the almost com- 
plete closure of the wound of the ventricle render it highly probable that the 
patient would have got well but for his imprudent exertions. 

102 Farquharson, Poisoning by the Seeds of Jatropha Ourcas. [July 

In conclusion, we think this must be regarded as a very interesting case, as 
it illustrates that wounds of the heart are not instantaneously fatal, and though 
itself terminating unfavourably, that they are not necessarily so. It shows, 
also, that wounds of this organ may cicatrize under, circumstances favourable' 
to such a process — and in a medico-legal point of view, is highly interesting. 
As suggested by a highly esteemed medical friend, an important therapeu- 
tical lesson may also be deduced from this case, viz., the necessity of the most 
perfect and absolute rest, and the observance of the horizontal position for a 
longer time than is usual in the treatment of such cases. 
Portsmouth, Va., April 23d, 1850. 

Art. XIII — Poisoning by the Seeds of Jatropha Curcas. By H. J. Farquhar- 
son, M. D., Assistant Surgeon U. S. N. Communicated by T. Harris, 
M. D., Chief of the Bureau of Medicine and Surgery, U. S. N. 

Two of our men, being ashore, tasted the seeds of the Jatropha curcas 
(which grows in great abundance on these islands), and finding them pleasant, 
ate of them, one to the extent of a handful, the other being satisfied with three 
or four. In both cases, vomiting and purging of a violent character came on 
in the course of an hour ; and in the instance of the man who had eaten but 
a small quantity, the effect only extended thus far. In the other case, more 
alarming symptoms rapidly supervened. The muscles of the extremities were 
contracted by violent spasms; the patient was affected with dizziness and 
vertigo, accompanied by great restlessness; the respiration was quick and 
panting ; the skin became cold and moist, and the pulse small, thready, and 
intermittent ; the heart's action was very irregular, and so weak that the 
impulse against the walls of the chest could with great difficulty be perceived. 
These effects of the poison upon the nervous system continued for the space 
of several hours. The seeds eaten were ripe, and of the kind used in small 
quantities by the inhabitants as an active purgative. 

The treatment consisted in the free use of anodynes and stimulants, after 
the continuance of vomiting and purging for a time rendered it probable that 
all the offensive matter had been discharged from the intestinal canal ; together 
with the application of a large mustard poultice during the state of depression. 
About five hours after the commencement of the attack, reaction occurred ; 
and shortly afterwards the patient fell asleep, and waked the next morning 
with no other ill effects remaining than a slight irritability of the stomach and 
considerable debility. 

U. S. Schooner Taney, Porto Pbaya, Cape de Verds, 

1850.] Spencer, Results of Fifteen Operations for Lithotomy. 103 

Art. XIY. — Results of Fifteen Operations for Lithotomy. By P. C. Seencer, 
M. D., of Petersburg, Virginia. 

In the following operations, performed within the last fifteen years, in 
Petersburg, Va., the instrument used was the lithotome cache, or the bilateral 
improved instrument of Baron Dupuytren. 

Case I. A free boy, four years of age, was operated on in September, 1833. 
Drs. Theophilus F. Gilliam and Birchett were present. From some unknown 
cause he died in the course of the night. His parents refusing positively to 
allow any kind of examination to be made, and as the los*s of blood was very 
inconsiderable and nothing unusual occurred in the operation, we were totally 
at a loss how to account for his death, unless it was from a nervous shock 
given to the system. The calculus extracted was about the size of a pigeon's 

Case II. Mr. Edward Ragsdale, of Virginia, aged seventeen years, was 
operated on October 1st, 1835. Drs. L. White, of Petersburg, and Morrison, 
of Brunswick county, assisted in this operation. We found a very large cal- 
culus incisted a little behind and laterally to the prostate gland, and so com- 
pletely imbedded as to require considerable force to separate it from the wall 
of the bladder. 

This operation was performed about fifty miles out of town, and I was 
unable to see the patient as often as I wished. For' a few days after the 
operation the case appeared as though it would do well. Later, however, he 
fell back, and steadily declined, and died on the fourteenth day. This result 
was not altogether unexpected, and was attributed to the great delay on the 
part of the patient in assenting to the operation, his weak condition, and the 
severity of the cystic irritation, which had so long existed ; for he would only 
submit to the knife in the last extremity. 

Case III. A slave, aged thirty-five years, operated on in May, 1837. 
After the result of the two previous cases, I invariably placed the patient 
under preparatory treatment, varying the treatment according to the circum- 
stances, and witnessed the happiest results. In this operation I was assisted 
by Dr. L. White and several students of medicine. We removed a very large 
calculus. The patient passed his urine naturally on the eighth day, had no 
fever of consequence, was walking about on the twentieth day, and in the 
course of a month returned home cured. 

Case IV. A slave, aged eighteen years, was operated on May 16th, 1837. 
In this operation I was assisted by Dr. L. White. We removed a very large 
number of calculi, which we found this bladder contained, many of which 
were so fragile that they were broken to pieces in attempting to bring them 
away. This patient, much to my astonishment, but more to my pleasure, 
passed his urine naturally on the fifteenth day, had no fever of consequence, 
but little after treatment, and returned home about the fortieth day cured. 

Case V. J. L. Long, of Virginia, aged seven years, was operated on No- 
vember 21st, 1838. I was assisted in this operation by Drs. L. White, Cox 3 
Michie, and several students of medicine. We removed a calculus of medium 

104 Spencer, Results of Fifteen Operations for Lithotomy, [July 

size. On the fifth day he passed his urine naturally. His recovery was 
rapid, and he returned home on the twenty-fifth day cured. 

Cass VI. Ripley Maggett, of Virginia, aged nine years, was operated on 
in May, 1839. Drs. Robinson, White, and Jones assisted in this operation. 
I made an opening into the rectum, and found it exceedingly difficult to effect 
a union of the parts. The only remedy resorted to was the solid stick of lunar 
caustic, introduced into the rectum on the finger of the left hand, an operation 
which I found necessary to be exactly repeated every thirty-six hours, for if I 
waited forty hours, his evacuations would pass through the cut, sometimes 
feces and urine commingled. The after treatment was more protracted than 
in any previous case. He returned home in about forty days, but with occa- 
sionally some moisture of the parts. He finally recovered, and his health has 
been perfectly restored. 

Case VII. Slave Ambrose, aged five years, was operated on June 1st, 
1840. Drs. White, Michie, and Jones assisted in this operation. We re- 
moved a calculus of more than ordinary size. He passed his urine naturally 
on the tenth day, and on the thirtieth returned home cured. Nothing un- 
usual occurred in the case. 

Case VIII. James Wells, of Virginia, aged four years, was operated on in 
September, 1844. In this operation I was assisted by Drs. White, Jones, 
and Couch. He passed his urine naturally on the eighth day, was walking 
about on the fifteenth, and returned home cured on the thirtieth day. 

Case IX. Mr. H Hardy, of North Carolina, aged eighteen years, was 
operated on November 21st, 1844. The necessary preparatory treatment 
was administered by Drs. Johnson and Cross, of the neighbourhood, when I 
visited him, attended by my friend Dr. J. F. Peebles, who assisted, in con- 
junction with the two gentlemen above named, in the operation. We removed 
an uncommonly large calculus. Although the operation was performed 
with our usual caution, and in the same manner as heretofore, yet the pudic 
artery was unfortunately wounded. It is perhaps worthy of remark that this 
accident did not at once manifest itself. It was only after the patient had 
been cleansed and replaced in bed that hemorrhage came on. After, in quick 
succession, he had discharged several coagula of blood of the full size and 
shape of the bladder, which he voided, impelled by a desire to urinate, symp- 
toms of sinking to such an alarming extent came on that it became necessary 
to replace him once more on the table, with the view of arresting the hemor- 
rhage. Whilst preparing a tent for this purpose, Dr. C. Cross inserted his 
finger into the wound, and feeling the jet of blood impinging against it, sud- 
denly made pressure on the spot. The manoeuvre was eminently successful. 
It was soon found that he had the bleeding entirely under control. Other 
measures were at once abandoned for this simple yet direct procedure. With 
unflagging zeal, altogether above all praise, Dr. C, despite the discomfort of 
his position, steadily maintained the pressure on the wounded vessel for five 
or six hours, when, gradually withdrawing his hand, we found that all bleed- 
ing had ceased. A sponge was then introduced on a canula, which was satu- 
rated with a solution of creasote, and allowed to remain until suppuration 
took place. 

The weak state of the patient, combined with much cystic irritation, which 
continued for some time, rendered his condition extremely precarious for 

1850.] Spencer, Results of Fifteen Operations for Lithotomy. 105 

several weeks. Under appropriate local and general treatment, however, he 
gradually gained and finally was perfectly re-established in health. 

Case X. Mr. J. R. Lunsford, of Virginia, aged twenty-seven years, was 
operated on January 17th, 1845. Drs. White, Jones, Couch, and Strachan 
aided in this operation. We removed two calculi, one of more than ordinary 
size, lying just in front of the prostate gland, the other in the bladder. Find- 
ing two, either over the common size, I examined very minutely with the 
finger and the instruments but found no other. I then proceeded to wash 
out the bladder with warm water and Castile soap, and replaced him in bed. 
He rallied at once, and was restored to complete health in an unusually short 
time. He passed his urine naturally on the tenth day, and returned home 
on the twenty-fifth day. 

Case XI. Master Rufus Stalling?, of North Carolina, aged four years, was 
operated on May 18th, 1847. I was assisted in this operation by Drs. J. F. 
Peebles, White, and Thweatt. The calculus was removed, and he com- 
menced passing his urine naturally the next morning. On the third day he 
passed all his urine per urethra, and returned to the interior of North Carolina 
on the nineteenth day from the operation, in fine health and condition. 

Case XII. Cornelius, a slave, four years of age, was operated on May 31st, 
1848. Drs. Peebles, White, Withers, and Thweatt assisted in this opera- 
tion. The calculus was removed, and he commenced passing his urine 
naturally on the fifth day, recovered his health rapidly, and returned home on 
the twenty-fifth day well. 

Case XIII. Master Louis Blitz, of Virginia, aged seven years, was operated 
on March 25th, 1849. I was aided in this- operation by Drs. White, Michie, 
Couch, and Hinton. We removed rather a small calculus. The health of 
this patient was extremely low, and his recovery gradual until the tenth day, 
when he commenced passing his urine naturally ; from that time he recovered 
rapidly, and returned home on the thirtieth day from the operation in good 

Case XIV. William, a slave from Williamsburg, Virginia, aged four years, 
was operated on April 29th, 1819. In this operation I was assisted by Drs. 
Peebles, Michie, Withers, Couch, and Durkin. We removed an uncommonly 
large calculus from the bladder, measuring one and a half inch in length, 
and large in proportion. The little boy had suffered from birth, and had 
become so much emaciated and relaxed as to render the operation most diffi- 
cult. After the first cut of the scalpel, such immense relaxation and prostra- 
tion of the lining membrane of the rectum took place, that I was compelled 
to lay the bistoury down frequently to replace the protruded membrane before 
I could complete the necessary section to get in the groove of the staff. In 
the progress of the operation, I unavoidably cut into the rectum as I appre- 
hended. Having committed the same error in the sixth case, or operation on 
R. Maggett, I at first feared much trouble, but suggested to my friend Dr. 
Peebles the propriety of locking up the bowels, with some preparation of 
opium, and permit the small opening in the rectum to heal as speedily as 
possible. To our astonishment and gratification, in a few days the part 
had healed and become firm, and on the fourth day he passed his urine natu- 
rally. Recovery in this case was as speedy as in any I had ever known. On 

106 Clark, Displacement of the Heart. [July 

the twenty-second day from the operation he returned to his home in Wil- 
liamsburg, full of life and health. 

The above mode of treatment I have since ascertained, first suggested, I 
believe, by M. Chomel, of Paris, is now generally employed in cases of intes- 
tinal perforation occurring in typhoid fever. It is certainly applicable to all 
cases of wounded intestines, and I perceive that Dr. Grerhard also recommends 
it in pneumothorax. 

Case XV. Mr. A. Weils, of Virginia, aged twenty-eight years, was operated 
on September 23d, 1849. I was assisted in this operation by Drs. Couch, 
Peebles, Hinton, and Rives. We removed a calculus weighing five hundred 
and sixty-three grains. The enormous size of the stone considered, it was 
with no little surprise and pleasure that we found him passing his urine natu- 
rally on the eleventh day. His general health improved rapidly, and the 
only after treatment pursued was the infusion of buchu through the day and 
a good and nourishing diet. It may be proper to remark here, that the 
external incision did not heal as rapidly as we anticipated. The healing pro- 
cess was very gradual, and it was not until the caustic had been several times 
applied that we could get the part to heal completely. 

Recapitulation of the Fifteen Cases. 

1st case 

died in 



of 12 hours. 

2d do. 

a it 


a 14 

■. clays. 

3d do. 


. naturally 

on the 8 th day. 

4th do. 




15th day. 

5th do. 




5th day. 

7th do. 




10th day. 

8th do. 




8th day. 

10th do. 




10 th day. 

11th do. 




3d day. 

12th do. 




5th day. 

13 th do. 




10th day. 

14th do. 




4th day. 

15th do. 




11th day. 

In the 6th and 14th cases the rectum was cut. In the 9th case the pudic 
artery was divided. 

Of the 15 cases, 9 were whites, all males; 3 boys, 4 nearly grown, and 2 
over 21 years of age. The number of blacks 6, 4 boys and 2 men. 

Art. XV. — Displacement of the Heart from Atrophy of the Left Lung. By 
C. J. Clark, M. D. of Jacksonville, Alabama. 

Laennec enumerates as causes of displacement of the heart, a solid, liquid, 
or serif orm effusion into either sac of the pleura, extensive tumours in the 
lungs, emphysema of this organ, and alludes to a prolapsus of the heart 
without any visible cause. 

Dr. Townsend (Cyclopaedia Pract. Med.) lays down as causes of displace- 
ment, 1st, effusion into the sack of the pleura; 2d, aneurism of the aorta; 

1850.] Clark, Displacement of the Heart 107 

3d, tumours; 4 th, pulmonary emphysema; 5th, diaphragmatic hernia; 6th, 
enlargement of the liver; 7th, hypertrophy; but says "in nine cases out of 
ten where the heart is removed out of its natural position, it will be found to 
have arisen from empyema or pneumothorax/'' 

Dr. Joy (Lib. Pract. Med.) mentions tumours, augmented dimensions of 
the neighbouring organs, morbid effusions, aneurisms of the aorta, emphysema 
and ascites ; and refers to one case by Dr. Abercrombie, in the Edinburgh 
Med. Transactions, in which the heart was displaced by " atrophy of one lung 
accompanied by a hypertrophic condition of the other." 

The following case will make one other case recorded, in which the displace- 
ment was caused by an atrophy of the lung. 

Gilbert Rakes, a man aged 52, had several years ago, as he said, while re- 
siding in the State of Virginia, a severe attack of inflammation of the left 
lung. Suffered ever since from attacks of cough, dyspnoea, and fever, which 
usually terminated or moderated each time, in a great degree, after the esta- 
blishment of copious purulent expectoration. For a long time has scarcely 
ever been entirely free from cough, some degree of dyspnoea and purulent 
expectoration; though these symptoms were much aggravated at times by ex- 
posure to atmospheric vicissitudes, &c. At these periods, his breathing par- 
took of an asthmatic character. 

I had known this man, myself, for four or five years, though I had never 
examined particularly into the nature of his disease. He looked haggard and 
prematurely old ; had very constant cough and expectoration, and was con- 
sidered consumptive. Yet he spent a great deal of his time on horseback, 
riding about the country, and frequently performed journeys of from fifty to 
two hundred miles without difficulty. 

I examined him hastily for the first and only time, on the 12th of May, 
1844, three days before his death. He was then sinking from hectic fever 
and copious offensive purulent expectoration. 

The chest was of the natural shape and dimensions, there being neither 
contraction nor dilatation at any point. Upon percussion, the right side of 
the chest yielded a healthy resonance; the left a liollow, drum-like sound, 
similar to that in extensive emphysema, but exaggerated. On auscultating the 
right lung, the normal sounds were heard, but unnaturally loud, while over the 
whole of the left side of the chest, except a space along the margin of the 
sternum, into which it subsequently appeared the right lung had protruded, 
there was a total absence of the vesicular murmur. Over the inferior lobe 
was heard a bronchial blowing, with some gurgling. Over the superior lobe, 
as you approached the clavicle, a loud bronchial blowing, attended with great 
gurgling. The heart gave no impulse to the anterior wall of the chest, beat 
tumultuously, and sounded as if at a distance. It beat so rapidly the two 
sounds were scarcely distinguishable; but there was no bruit or other abnor- 
mal sound perceptible. Upon percussing the posterior part of the chest, there 
was decided flatness over this lung. Auscultation discovered no vesicular 
murmur here ; but great gurgling and greater distinctness of the heart's sounds 
than anteriorly. 

Post-mortem Examination. — Ten hours after death, with the assistance of 
Dr. J. C. Francis, I made an examination of the contents of the thorax. The 
first thing that attracted attention upon raising the sternum, was the protru- 
sion of the right lung, which was greatly hypertrophied into left side, passing 
beyond the line at which I had divided the cartilages of the ribs. Pushing 
the lung back towards the right side, a large cavity or vacuity was discovered 
in the left, in the place the left lung and heart should have occupied. This 

108 Clark, Displacement of the Heart. [July 

cavity was a total vacuum, so far as solids or liquids were concerned. The 
diaphragm had risen considerably higher on this side than on the right. At 
the bottom of this cavity was found the pericardium and the heart, and be- 
neath them the lung, completely atrophied, and shrunk to one-sixth the healthy 
size, and firmly adherent to the posterior wall of the chest. Commencing at 
the spine, and passing along the ribs towards the sternum, the adhesion ex- 
tended about one-third the length of the ribs, being caused by a dense, thick, 
false membrane (or mass), so strong, I could not possibly tear it away with 
the utmost strength of my hands, but which I had to dissect away with a 
knife. This thick fibrous membrane, by which the lung was bound down to 
the costal pleura, when dissected out, proved to be the walls of a sac which 
contained a large quantity of offensive purulent matter, such as the patient 
had expectorated during life. There were also a number of small abscesses 
throughout the atrophied lung, containing the same kind of pus. In these 
some of the smaller bronchial tubes terminated abruptly, having ulcerated, 
and presenting open mouths in the suppurating cavities. Every portion of the 
lung had lost its cellular structure, the parts between the abscesses being in 
a state of gray induration, and every portion sinking in water instantly. The 
pericardium was firmly bound to the atrophied lung, and this had evidently in 
contracting, drawn the heart along ivith it, almost into contact with the poste- 
rior third of the sixth and seventh ribs. 

This had evidently been a case of pleurcf-pneumonia, terminating in adhe- 
sions between the two pleurae at the back of the lung, and the pleura and 
pericardium, hepatization, and the deposit of plastic lymph on the surface, and 
in the substance of the lung, and the formation of abscesses. Subsequently, 
the contraction of the false tissue around and within the lung had compressed 
it, while a disintegration was going on in the abscesses, the debris being dis- 
charged with the secretions of the suppurating surfaces, constituting the offen- 
sive purulent expectoration described — the whole resulting in the atrophy of 
the organ. As the lung diminished in size, and the contraction of the false 
tissue went on, the heart, from the adhesions of the pericardium, was drawn 
after the contracted lung, and thus displaced. It is worthy of remark that, 
although great displacement had existed, and for a long time, no organic dis- 
ease of the heart had resulted from it, or any disturbance of its functions, 
unless the slight habitual dyspnoea might be attributable in part to some irre- 
gularity of the circulation. Had this been the case, it would probably in 
this time have caused some change in the size of the cavities, and the thick- 
ness of its walls. 

Although there was no contraction of the chest, we might diagnosticate an 
atrophy of the lung in such a case as this by the presence of the hollow, drum- 
like resonance with the total loss of the vesicular murmur, in the absence of 
dilatation of the chest, widening of the intercostal spaces, and other evidences of 
emphysema. The displacement of the heart would be evident by the absence 
of the ordinary flatness yielded on percussing the cardiac region — from its 
giving no impulse to the ribs, and beating to the ear as if at a distance when 
examined in front, and from the presence of its sounds in the new position to 
which it had been removed. 

Jacksonville, Nov. 21th. 1849. 

1850.] 109 


Art. XVI. — A Systematic Treatise, Historical, Etiological, and Practical, on 
the Principal Diseases of the Interior Valley of North America, as they 
appear in the Caucasian, African, Indian, and Esquimaux varieties of its 
Population. By Daniel Drake, M. D. Cincinnati, 1850: 8 vo. pp. 878. 

We hail with pleasure the appearance of this long expected work of Dr. 
Drake, on the medical topography and diseases of the valley of the Mississ- 
ippi. Our anticipations in relation to it, founded upon the known abilities, 
and untiring industry of the author, and the time and labour he is known to 
have devoted to the collection of the materials required for its successful exe- 
cution, have always been in the highest degree favourable. These anticipa- 
tions have not been in the least disappointed, now that the work has appeared. 
It will, we are convinced, be ranked as the most valuable and important 
original production, of a strictly professional character, that has yet appeared 
from the pen of any of our own physicians. 

The volume now published comprises, 1st, the topographical, hydrographi- 
cal, climatic, physiological, and social etiology of the great Interior Valley; and 
2dly, that portion of the febrile diseases of the valley included under the 
heads of intermittent fever, simple, inflammatory, and malignant, with the 
corresponding varieties of remittent fever. The first part, or that devoted to 
the medical topography and climate of this extensive region, and to the cha- 
racter, modes of living, habitations, occupations, pursuits, habits, and recrea- 
tions of its population, occupies the first seven hundred and two pages. 

An idea may be formed of the extent of region, to the medical history of 
which the work of Dr. Drake is devoted, from the following extract taken 
from its initial chapter. 

"Of the area of this great intermontane region, it is not easy to speak with 
much precision. To the south, its latitudes vary from the eighteenth to the 
thirtieth parallels ; in the north, from the fiftieth to the seventieth. In the south, 
its eastern margin is found near the eighty-first meridian; its western, in the 
one hundred and fifth ; but in the fifty-third degree of latitude, it advances east 
to the fifty-sixth meridian, and west to the one hundred and sixteenth ; finally, 
in the sixty-eighth parallel, its western margin is found in the one hundred and 
thirty-sixth degree of longitude. 

"If we assume eight millions of square miles as the area of North America, 
the valley cannot be estimated at less than six millions, or three-fourths of the 
whole continental surface. Its northern half, however, is rendered nearly un- 
inhabitable by the state of its surface and its climate ; and, therefore, the por- 
tion which presents objects of immediate interest to the medical etiologist does 
not exceed three millions of square miles, of which, as yet, not more than one- 
third has acquired even a sparse population." 

The medical topography of each portion of this region is separately con- 
sidered; beginning with the coast of the Gulf of Mexico, and the localities in 
and around the delta of the Mississippi; proceeding thence to the bottoms 
and bluffs of the river Mississippi above its delta ; to the regions west of the 
gulf and river, thence to the regions east of the gulf and of the Mississippi, 
south of the Ohio basin ; thence to the Ohio basin, the regions on the northern 
side of that river, and the regions north of the Ohio basin. Then to the eastern 
No. XXXIX.— July, 1850. 8 

110 Review. [July 

or St. Lawrence basin ; the basin of Lake Erie, of Lake Ontario, and, finally, 
the Hudson and arctic hydrographical basins. 

The vast extent of this field of inquiry, which would, at first view, seem to 
be a great disadvantage, Dr. Drake considers to be, in fact, highly favourable 
to the development of results; as it enables us to trace a disease, in continuity, 
from its points of greatest prevalence, to its disappearance under new physical, 
or moral and physical conditions. 

To the medical inquirer, the study of topography, in conjunction with the 
extent, character, condition, pursuits, habits, clothing, dwellings, means of 
sustenance, including the ordinary diet and drinks of the population, is chiefly 
important in reference to its influence upon health, vigour, and longevity, and 
its especial bearing upon the etiology of disease ; consequently, to enable him 
to arrive at any satisfactory solution of tfiese questions, it is essential that we 
be made acquainted with the ordinary duration of life, the prevailing diseases, 
their frequency and character, and the prevailing endemic and epidemic mala- 
dies in each location or region described. Unfortunately, however, medical 
statistics have been but little attended to by the physicians of this country, 
and the loose general statements, imperfect records, and indirect sources of 
information from which opinions, in regard to the sanitary and etiological in- 
fluence of climate and locality, are usually derived, can never be made the 
basis of any satisfactory conclusions in this respect. While, therefore, we 
receive with pleasure every contribution to the accurate topographical descrip- 
tion of the different regions of our country, we must wait patiently until a 
sufficiently extended series of accurate medical statistics shall enable us to apply 
our knowledge of the topographical, hydrographical, climatic, physiological, and 
social history of our country, to the solution of the important questions con- 
nected with the etiology and possible prevention of its diseases. 

"In describing," remarks Dr. Drake, "our topography, climate, and states 
of society, I might have noted the relative prevalence of many diseases ; but 
such a course would have been attended with numerous embarrassments. I 
selected two, therefore, which, from universal observation, are known to have a 
most intimate connection, in their orgin or prevalence, with soil and climate ; 
and have very generally noted the degree of their occurrence, or their absence, 
in each locality ; thus endeavouring to maintain in the mind of the reader the 
connection which, in nature, exists between topography and etiology. He must 
not, however, forget that in the study of many others, a reference to the topo- 
graphical descriptions will frequently be made." 

There can be little doubt of the general accuracy of the statements made 
by Dr. Drake in reference to the endemical diseases of the different sections 
of the great valley. His inquiries into these have, evidently, been made with 
great care and industry, and, in a large number of instances, his information 
has been derived from personal intercourse with the most experienced and 
intelligent physicians of the particular locality. The same remarks may be 
made, also, in regard to the account given in the work before us, of the non- 
endemial diseases that are most frequently met with throughout the valley. 
Dr. Drake has collected all the facts bearing upon this important branch of 
his subject that were within his reach, and has presented them in as accurate 
a form as they were susceptible of assuming. In the absence, however, of a 
correct series of medical statistics, with all his industry and research, our 
author's account of the comparative prevalence and mortality of different dis- 
eases, in the several portions of the valley, are deprived of that precision so 
essential to arriving at correct conclusions in regard to the etiological influence 
of locality and climate ; while, for determining the influence of these upon 
the duration of life, we are left without any reliable data. 

1850.] Drake on Diseases of Mississippi Valley. Ill 

The plan pursued by Dr. Drake in his topographical description of the 
valley, will be understood from the following sketch of it, given in the intro- 
duction to the first part of his treatise. 

" As an introduction to the difficult task of topographical description, over so 
large a surface, I have attempted to prepare, as it were, a geographical back- 
ground, fitted (to continue the metaphor) to bring out, more distinctly, the cha- 
racteristics of each locality. Thus, a comprehensive outline of the physical 
geography and hydrology of the whole region precedes all local description ; 
and in the unsettled portions of the valley, comprehends all that seemed neces- 
sary to our purpose. I have also sought to give the progressive togography a 
geological basis, a hydrographical guidance, and a climatic order, all of which, 
it will be seen, was in some degree practicable. Beginning with the shores of 
the Gulf of Mexico, and advancing north, we pass successively over all the 
geological formations of the valley, from the newest to the oldest. Again, com- 
mencing at the gulf, we start on a proper hydrographical base line, and by 
ascending the Mississippi, are guided in the same direction as before. Again, 
in starting from the gulf, below the twenty-third degree of north latitude, we 
get a tropical base line for our climates, and in advancing to the north, reach, 
progressively, higher latitudes, greater elevations, and further distances from the 
sea. Finally, while ascending the Mississippi, if we turn from it to the east 
or west, we constantly attain to a higher level and a dryer surface. 

" If we pass out of the valley of that river into the basin of the great lakes, 
and the St. Lawrence, we find similar, though less striking relations. Thus, 
in descending to the south, from the summit level beyond Lake Superior, to the 
western end of Lake Erie, we pass regularly from older to newer geological 
formations — from a wetter to a dryer surface — from higher to lower levels ; and 
when we turn from the extremity of the latter lake, and advance in the direc- 
tion of the St. Lawrence, we pass from newer to older geological deposits ; from 
lower to higher latitudes, and from higher to lower elevations, until we reach 
the tides in that river. Lastly, if we pass over the dividing ridge between the 
waters of the southern and northern parts of the valle}', and descend the rivers 
which disembogue into the frozen seas of the north, we travel most of the way 
over primitive rocks, are constantly arriving in a higher latitude, and as con- 
stantly sinking to a lower level, until we reach the ocean. 

"It has been my aim to keep these various relations in view, and so to pro- 
ceed with the descriptions as to have no locality insulated, but each to follow 
some other in a natural sequence, and thus to arrange the whole into one topo- 
graphical system. " 

The plan thus sketched out, extensive as it is, has been carried out in a 
manner highly creditable to our author, and in one calculated to render the 
labour of those who shall hereafter pursue the investigations of the nature 
and etiology of the diseases of the interior valley of North America compara- 
tively light. 

It is not our intention to attempt a review of the first portion of the trea- 
tise before us. Such an attempt would be presumptuous in any one who has 
not prepared himself for the task by the same laborious and protracted course 
of exploration and research which has been pursued by the author in the 
collection of his materials. The work is professed!}' an exposition of facts 
and careful observations, to test the accuracy of which is the work of time 
and continuous observation. While few, if any one, besides the author, could 
be found competent to its production, there is scarcely any one who is now pre- 
pared to examine critically the truthfulness of its descriptions throughout, or 
the correctness of all its general conclusions from the facts adduced. 

Extensive as his explorations have been, large regions of country remain 
un visited; and Dr. Drake admits that 

"Many conclusions at which he has arrived, might possibly have been differ- 
ent, had the facts, which these regions could have furnished, been obtained by 

112 Review. [ Ju -/ 

him. Yet, as his personal examinations were carried through eighteen degrees 
of latitude, and nearly as many of longitude, he trusts that facts which may, in 
some degree, stand as representatives of the whole, have been collected ; and, 
therefore, that no general conclusion will be found radically wrong." 

The second part, or that devoted to climatic etiology, will be found replete 
with valuable observations, equally interesting to the general as to the medical 
reader. It will not admit, however, of any very satisfactory analysis. 

In Section V., a table is presented showing the average of the mean tem- 
peratures, at thirty-two localities, of the six pairs of months, beginning with 
January and July, and travelling through the calendar year. To this table 
are appended the following remarks : — 

"The results presented in the footing of this table are not destitute of inte- 
rest. They show that, of the six pairs of months, but one varies from the 
mean annual temperature to the extent of a degree ; they show, also, that the 
mean temperature of February and August approaches nearest to the mean 
temperature of the year ; and that the average of June and December departs 
widest from it. The former are the last winter and last summer months ; 
the latter are the first summer and first winter months. We likewise see that 
four of the pairs rise above the mean annual heat, two fall below it. Those which 
present an excess are the four pairs which succeed to the solstices ; those which 
offer a deficiency are the pairs which precede, and the pairs which include the 
solstices ; the latter showing the greater deficiency of the two, 1°.18. It would 
be interesting to know whether this is the consequence of inaccurate observa- 
tions, or in accordance with a law of our climate. 

"As the mean heat of each pair of months presents so close an approxima- 
tion to that of the year, it follows, that the mean temperature of the latter 
may be ascertained, by observing that of the former; but we must bear in 
mind, that this close approach is made, by the observations of the whole table, 
which embraces stations in various parts of the valley from south to north. In 
particular portions of it, the coincidence may not be so near" — 

"It might be supposed that, when we know the mean annual temperature of 
any particular place, as Nashville, for example, and observe the temperature of 
a month, as of February, we might predict the heat of August. If, for in- 
stance, February were very cold, that August would be very hot; or if May 
were unusually hot, November would be correspondingly cool ; or, taking sea- 
sons, it might be expected that a rigorous winter would be followed by an 
ardent summer ; a warm spring by a cold autumn, et vice versa. But there 
are two sources of uncertainty in these predictions. First, it may be that the 
winter and spring should have been compared with the summer and autumn 
which preceded, instead of following them ; and second, we know that the 
mean heat of different years, at the same place, is not the same, but varies 
several degrees. It might be, then, that a cold February or April would not 
be followed by a hot August or October ; for the whole year might be one of 
low temperature. Nevertheless, if any month depart widely from its proper mean 
heat, there is, prima facie, much reason to expect that its counterpart will vary as 
much in the opposite direction. This mode of prognosticating may, perhaps, 
be turned to some account, in deciding beforehand on the probable duration of 
the prevalence of bilious fever in autumn. Thus, if April and May should be 
unusually intense, it might be expected that October and November would be 
so cool as to give an early termination to autumnal fever; and if June should 
be violent in its heat throughout, a cold December and an early setting in of 
winter might be expected." 

Part the third comprises an excellent sketch of the population of the 
valley, its physiological characteristics, modes of living, including diet, drinks, 
clothing, lodging, habitations, occupations, pursuits, exercise, and recreations. 

Were we to indulge our inclinations, to dwell on every point of interest 
contained in the sections devoted to these several particulars, the very judi- 
cious remarks of our author would lead us into a somewhat extended notice, 

1850.] Drake on Diseases of Mississippi Valley. 113 

interspersed with copious extracts. But we prefer a general expression of 
approval, in the full belief that no American physician will consider his 
library complete without a copy of the work of Dr. Drake, and that all who 
desire instruction on topics interesting alike to all will be desirous of devoting 
an early opportunity to its attentive perusal. 

The author concludes the first book as follows : — 

"Our general etiology is now brought to a close. If the reader has found its 
perusal a work of labour, he will be prepared to estimate the amount which has 
been required to collect, arrange, condense, and give unity to so many diversi- 
fied facts, connected with a country of such vast extent, and races of people so 
various. In doing this, I have introduced nothing which I did not consider 
necessary to a full understanding of the diseases, which are to come under our 
consideration ; for all peculiarities of constitution, both corporeal and mental, 
exert a modifying influence on disease. In this country, these peculiarities are 
not yet largely developed, but we may study their causes, and, as far as possi- 
ble, infer their effects, which our distant successors will see in their full de- 
velopment. A synthesis of varieties and races is going on ; and the result, I 
may here repeat, must be a new national constitution, physical and mental, of 
which the Anglo-Saxon, itself a compound, will be the basis and the governing 
element. The physicians of a future day will see, what we cannot now, a pre- 
vailing temperament, a stature, form, complexion, and physiognomy, charac- 
teristic of an indigenous, but greatly compounded race ; with its own physical, 
intellectual, and moral constitution ; its special liabilities and exemptions from 
disease ; its national idiosyncrasies, and the required peculiarities of hygienic 
regimen and therapeutic treatment. In the course of this development, what 
hereditary diatheses may disappear, and what new ones take their places; what 
new maladies may arise, or old ones cease or become greatly modified under 
the joint influence of mingled blood, of climate, water, occupations, modes of 
living, customs, and moral, social, and political influences, cannot be specified; 
but a few predictions may be hazarded. 

" 1. Autumnal fever will decrease, and typhus and typhoid fevers become 
more prevalent. 

"2, Gout will occur oftener than at present. 

" 3. The diseases produced by the intemperate use of ardent spirits will 

"4. Consumption and scrofula will increase. 

"5. Apoplexy, palsy, and epilepsy will become more frequent. 

"6. Diseases of the liver will become less, and those of the mucous mem- 
brane of the bowels more prevalent. 

"7. Lastly, mental alienation will be more frequent. 

" We are now prepared to enter on the study of particular forms of disease. 
In doing so, I shall not adopt the classification presented in any system of 
nosology, nor invent a new one ; and yet I hope to proceed with such a degree 
of method as will be found sufficient to avert confusion. The second book will 
be devoted to febrile diseases, under the five following heads. First, autumnal 
fever; second, yellow fever ; third, typhus fevers ; fourth, eruptive fevers ; fifth, 
phlogistic fevers, or the phlegmasia?. The transition from general etiology to 
that fever, which, in its origin, has a close connection with soil and climate, is 
natural; and the transition from the phlegmasia to many other forms of dis- 
ease will be found equally natural ; and hence I have placed them last, although 
in a system of elementary pathology, or nosology, they should stand first." 

The present volume comprises only so much of the second book as treats 
of autumnal fever, intermittent and remittent fever, with their varieties. 

The autumnal fever prevails from the extreme southern limits of the valley. 
Below the 33° of latitude, its eastern limit is the Atlantic Ocean, above that 
parallel its barrier on the east is the Appalachian Mountains, into the very 
gorges of which, however, it ascends by the valleys which penetrate their 
flanks. Its boundaries to the southwest are the Cordilleras of Mexico and 
the southern Rocky Mountains; while, in higher latitudes, it ceases on the 

114 Review. [July 

great plains of our western desert long before we reach those mountains. It 
is almost unkown at the distance of three hundred miles from the western 
boundary of the States of Missouri and Iowa, and above the latitude of 37° N. 
To the north it does not prevail as an epidemic beyond the forty-fourth paral- 
lel, and ceases to occur even sporadically about the forty-seventh. 

In proceeding to consider the conditions which impose geographical limits, 
and give unequal prevalence to autumnal fever, under the heads of soils, living 
vegetation, and surface waters, Dr. Drake remarks that it is a safe generali- 
zation to affirm that, all other circumstances being equal, autumnal fever 
prevails most where the amount of organic matter is greatest, and least where 
it is least. He considers that a diligent study of the topographical descrip- 
tion given in the first part of the first book of his treatise will sustain this 
conclusion, and demonstrate that decaying organic matter is one of the condi- 
tions necessary to the production of autumnal fever, either by supplying the 
material for the generation of a poisonous gas, or by forming a nidus or hot- 
bed for animalcules or vegetable germs. Surface water is another condition 
required for the production of the disease. By impregnating the air with 
vapour and giving a high dew point — by promoting a luxuriant vegetation, 
and aiding in its decomposition — by promoting those chemical actions in 
certain soils supposed by some writers to generate exhalations which produce 
the fever, it is essential to the production of both animalcules and microscopic 
plants ; and by means of evaporation and condensation it causes electrical 
changes. Thus, water is a necessary element in all the hypotheses which 
have been framed to account for autumnal fever. An elevated temperature 
is another of the conditions necessary for the production of this fever. 
The disease prevails perpetually and virulently within the tropics, but ceases 
long before we reach the polar circle. The modes in which heat may operate 
as an etiological agent are, according to Dr. D., by predisposing to the disease 
in consequence of its action directly upon the surface, and indirectly upon the 
internal, especially the abdominal, organs. The cool nights of early autumn, 
acting upon the same over-stimulated organs, may still further concur in 
producing an attack of the fever. Heat also promotes evaporation, and gives 
to the atmosphere a high dew point ; it favours the decomposition of organic 
matters; it facilitates the multiplication of minute visible and cryptogamic 
plants, and may be presumed, therefore, to multiply the microscopic organiza- 
tions, both animal and vegetable. By evaporating the superfluous water of 
ponds, swamps, marshes, and sluggish streams, it brings the organic matter 
which they contain or cover in a condition more favourable to rapid decay. It 
dries the surface of the ground after the rains of spring and summer, and may, 
as has been asserted, cause it, in the act of dessication, to send forth deleterious 
exhalations, different from those generated in deposits of decomposing organic 
matter. Finally, it disturbs the equilibrium of the electricity of the atmo- 

" Thus solar heat plays an indispensable part in every hypothesis which 
has been proposed to explain the origin of autumnal fever ; answering equally 
well for the advocates of combined heat and moisture — miasmatic exhalations 
— microscopic beings, and atmospheric electricity." 

" We have now," remarks Dr. I)., " reviewed all the obvious conditions which 
seem to concur in the production of our autumnal fever, and endeavoured to 
assign the modus operandi and influence of each. We have seen the necessity 
of their concurrence from the fact that the absence of any one puts an end to 
the prevalence of the fever. These conditions are dead organic matter, resting 
on or blended with the mineral elements of the soil ; water not in any, but in a 
certain quantity, and temperature, above the sixtieth degree, continuing for at 
least two months." 

1850.] Drake on Diseases of Mississippi Valley. 115 

Dr. Drake next passes in review the leading hypotheses that have been 
advanced to explain the efficient cause of autumnal fever. The meteoric hy- 
pothesis is first considered, and a number of facts are adduced, which appear 
to him conclusive in their bearing against its validity, excepting so far as 
certain atmospheric conditions may act as exciting causes. He believes that 
we are, consequently, thrown upon the alternative, a deleterious agent, diffused 
in the atmosphere — the positive existence of which seems ; he thinks, to be 

" Now this agent may be either one of two kinds — inorganic or organic — and 
both have a prima facie advantage over the meteoric hypothesis in demanding 
the concurrence of all the conditions — heat, water, and dead vegetable and 
animal forms — which have been shown to be always present wherever autumnal 
fever prevails ; while the last is left out of account by the meteoric hypothesis." 

We cannot see with Dr. Drake how the rejection of the meteoric hypothesis 
necessarily involves the adoption, as the etiological agent in the production of 
autumnal fever, of a poisonous matter diffused throughout the atmosphere. 
That this fever is of malarious origin appears to us proved by all the facts 
connected with its rise and prevalence ; but may not this morbific condition of 
the atmosphere be produced by other changes in its constitution than the 
addition to it of some unknown deleterious agent ? That the presence or 
character of this supposed morbific change in the condition of the atmo- 
sphere has not been demonstrated, we admit ; but, then, let it be recollected 
that the same is true of the presence of a morbific poison. Although Dr. 
Drake thinks that the facts which have been adduced seem to establish " the 
positive existence" of this poison, yet in examining the miasmatic and vegito- 
animalcular hypotheses in explanation of the etiology of autumnal fever, he 
has himself admitted that while the conditions under which that disease ap- 
pears are sufficiently clear to observation, " the existence of a special gaseous 
agent resulting from them remains to be proved." Although he thinks that 
the etiological history of autumnal fever can be more successfully explained 
by the vegito-animalcular hypothesis, yet he confesses that in the present state 
of our knowledge, it also must stand as a mere hypothesis, and will not " be 
entitled to the confidence of the profession until many additional facts are 
brought to its support." And, in general conclusion, while he asserts his full 
belief in the existence of a specific agent as the definite, efficient cause of 
autumnal fever, Dr. Drake admits our ignorance of any such cause, and 
therefore speaks of it as a morbific agent, " known only by its effects upon the 
living body." In a subsequent section, he remarks, in regard to the mode of 
action of this agent, 

"Relying on its effects to guide us in an estimate of its character, we may 
say that the efficient cause of this (autumnal fever) is a peculiar poison, of a. 
sedative and irritating quality, somewhat like the narcotico-irritating gases, or 
certain solid and fluid bodies, which in large doses, destroy life suddenly, by 
reducing power, and in smaller portions weaken while they pervert the func- 

This posion Dr. Drake supposes to enter the blood through the lungs. His 
reasons for this supposition are as follows :— 

" First, We have seen that there is no evidence that the morbific impression 
of this cause is made on the skin or mucous membranes with which it is in 
contact, and yet its action on the system is a reality ; hence we may conclude 
that it penetrates through some surface to the blood. Second. As various gases, 
vapours, and odours penetrate the thin parieties of the vessels of the pulmo- 
nary membrane, we may conclude, from analogy, that the efficient cause of this 
fever may do the same. Third. Dr. Stevens has shown that, in the endemic 

116 Review. [July 

fevers of the West Indies, the blood suffers deterioration before the phenomena 
of fever have manifested themselves in the functions of the solids. Fourth. 
The universality of functional lesion, and, in most cases, its equality among 
the different organs ; in other words, the involvement of the constitution, would 
seem to indicate that the remote cause has acted throughout the whole organ- 
ism at the same time. Fifth. A prominent and most dangerous condition in 
autumnal fever is the impaired state of the calorific function, found in its 
highest degree in algid intermittents. As the blood evidently plays an import- 
ant part in this function, may we not conclude that in these remarkable cases 
it has undergone a change in its composition or constitution which unfits it for 
the development of caloric ? Whatever may be the agency of the nervous 
system in this function, it is undeniable, that the blood is immediately and 
deeply concerned, and highly probable, that its agency is according to chemical 
principles. Should it, then, be altered in its constituents or their mode of 
union, an alteration in its calorific agency would be inevitable. It must not be 
forgotten, however, that in the stage of febrile excitement there is increased 
heat. Nevertheless, there are cases in which, during that stage, the extremities 
continue cold. Sixth. An argument in favour of this hypothesis may, perhaps, 
be found in the well-known fact that a suppression of perspiration, by lodging 
in the open air, tends to excite the disease, and that a copious perspiration, 
effected by art, in the forming stages, often arrests it. While the function of 
perspiration continues active, the poison absorbed by the lungs may pass off 
through the skin ; but, being arrested in that exit, may, by its accumulation, 
prove mischievous, and when it has already begun to do harm, a copious sweat 
may relieve the system of such an amount that the fever may be averted. 
Seventh. Nearly connected with these views, and tending to the same point, is 
the fact, that as long as the nights continue warm, the disease does not become 
epidemic ; but as soon as they become so cool as to check the functions of the 
skin, by diminishing its capillary circulation, and surrounding it with a damp 
atmosphere, from the liberation, by the reduction of temperature, of a portion 
of vapour, which was insensible at a higher degree of atmospheric heat, the 
fever assumes an epidemic character." 

The poison thus introduced, Dr. Drake supposes to become, on the one hand, 
mingled with the blood, which it deteriorates by disturbing the equilibrium of 
its affinities, and changing its isometric character; and, on the other, by acting 
directly upon the entire internal surface of the arteries, veins, and heart, pro- 
ducing throughout the organism reduction of vital energy, obtuseness of sen- 
sibility, suspended or perverted secretion, and diminished calorification. If 
we combine these effects with those supposed to be produced by the altered 
state of the blood on the nervous system, and all the organs of secretion, and 
with the whole, those which must necessarily and immediately result to that 
fluid, from the reactive influence of the diseased solids, we have the patholo- 
gical state which, according to our author, constitutes the first effect of the 
remote cause, and the first stage of the fever. 

After tracing the impression of these morbific impressions up to the full 
development of the cold stage, followed by the morbid reaction which con- 
stitutes the hot stage, or that of excessive excitement, Dr. Drake remarks : — 

"In whatever way it is brought about, when death does not happen in the 
stage of depression, high excitement ensues; and other phenomena, indicating 
new pathological conditions, offer themselves to our notice. 

" 1. The blunted sensibilities of the patient become morbidly acute — pain 
occurs in parts not previously affected, or becomes sharp where before it was 

"2. The heart, in most cases, acts with unwonted force, and the blood is 
thrown toward the periphery of the body, but circulates with a rapidity which 
brings it speedily back upon the viscera. 

"3. The calorific function is not only restored, but becomes excessive, and 
the intolerance of heat is augmented. 

1850.] Drake on Diseases of Mississippi Valley. 117 

" 4. The liver acts with uncommon energy, and the secretion and excretion 
of bile are correspondingly great ; at the same time the bilious hue may become 
deeper than before, indicating either return of bile into the blood from the 
liver, or extraordinary development of its elements in that fluid. 

" 5. After the lapse of a few hours in the intermittent, and of a longer por- 
tion of a day in the remittent form, this excitement abates, and an intermission 
or remission is declared, by the tranquillity of the patient, the abatement of 
the force and frequency of his pulse, and the occurrence of more or less per- 

"6. It may happen, however, that when the stage of excitement comes on, 
some organ or organs will remain in a state of hypersemia, and pass into in- 
flammation. These are, generally, the viscera of the abdomen, chiefly the 
spleen, liver, and gastro-enteric mucous membrane. 

" a. Splenitis is so common an accident of our autumnal fever, especially 
our inflammatory intermittent^, as to' suggest that we can nowhere look for the 
true anatomical character of that fever more successfully than in the spleen. 
Why it should be so great a sufferer cannot, perhaps, be told, except that it 
becomes greatly engorged in the forming stage of the fever. 

" b. Next to the spleen, or equally with it, the liver is liable to fall into inflam- 
mation upon the access of the hot stage ; but this is more especially the case in 
the remittent type. 

"c. The mucous membrane of the stomach and duodenum, with that of the 
common gall duct, are liable to pass into the same condition. 

"Thus all the subdiaphragmatic viscera, except the pancreas, are subject to 
inflammation in this fever. Sometimes, however, from idiosyncrasy, or the co- 
operative action of certain causes, inflammation of the brain, or its envelopes, 
may happen ; and when the fever makes its attack, late in autumn, the com- 
bined action of vicissitudes of temperature and of the specific cause, developed 
at an earlier period, may determine the inflammation upon the lungs or pleura. 
Wherever the inflammation may be seated, it complicates the case, and creates 
a new kind of danger. Although it may abate with the subsidence of the hot 
stage, it does not cease. The affected organ shows signs of suffering during the 
apyrexia, which it renders imperfect. The succeeding exacerbation may be 
prolonged by it, and an intermittent may thus be converted into a remittent ; 
while the latter, not unfrequently, as already said, passes nearly into a con- 
tinued type, from the same pathological cause. But the most dreaded combi- 
nation of this kind, which we meet with in the Valley, is that in which an in- 
flammation of an organ is associated with such a depression of the general forces 
of the system, that but a feeble reaction occurs. That this is a reality, both 
the symptoms and post-mortem appearances have shown. Such inflammations 
are never very acute. The organ is greatly engorged, but the actions which 
constitute inflammation are feeble ; and, after death, appearances which indi- 
cate congestion or passive hyperemia, are more conspicuous than the vestiges 
of true inflammation. Between these cases and mere congestion of the organ 
there is often but a shade of anatomical difference." 

The theory presented by Dr. Drake of the development and leading results 
of autumnal fever is ingenious and plausible ; unfortunately, however, it is 
based upon a mere assumption—namely, that the first disturbing cause, by 
the impression of which is produced the entire chain of pathological actions 
and phenomena which constitute the fever, is a material poison introduced 
through the pulmonary circulation into the blood. Such may possibly be the 
fact, but at present we have not the slightest evidence to prove that it is so. 
The exposition given by Dr. Drake, of the development and results of 
autumnal fever, taken simply as a history of the lesions and phenomena by 
which these are attended, is interesting and instructive. 

It is not our intention to follow the author through his history of the dis- 
ease, and its several varieties, and his directions for its treatment. The 
history of the simple form of the disease he omits ; its symptoms, progress, 
and sequelae being, throughout the Valley, substantially the same; and quite 

118 Review. [July 

identical with those exhibited in all times and in every country. The cura- 
tive measures directed by Dr. D. are based upon sound therapeutical princi- 
ples. He is no advocate for any exclusive practice or special formulae or 
heroic doses of medicines, but guided, in each case, hj the pathological con- 
ditions indicated by the symptoms, applies the means which common expe- 
rience has shown to be the best adapted for their removal. Bis remarks on 
the administration of quinia are particularly sound. In relation to this 
remedy, the following extract will probably be interesting to our readers : — 

"Two opposite conditions of the system contraindicate the use of quinia: 
1st. A high degree of phlogistic diathesis, with arterial fulness ; 2d. Great de- 
pression of the vital forces. 

" The effects which have been ascribed to it characterize it as a medicine 
which produces, in the innervation, a peculiar change, and constitute it an 
alterant of a particular kind. Now this effect, as experience has shown, stands 
specifically opposed to the effect produced by the cause of autumnal fever ; and 
on this accidental opposition depends its efficacy, in all the varieties (though 
not in all the stages and complications) of that fever. In reference to them, it 
may be said to be antiperiodical, and antidotal. It is not, however, infallible ; 
for its curative relations to autumnal fever are like those of mercury to syphilis, 
or of iodine to goitre and external scrofula. If they succeed beyond all other 
known remedies in those diseases, so does the sulphate of quinine in the dis- 
eases of which we are now treating : if they occasionally require preparatory 
and adjuvant treatment, so does it; if they sometimes fail, so does the remedy 
we are considering. 

" I have said that I should take the sulphate of quinine as the representative 
of the cinchona bark ; but it seems proper here to remark that their effects are 
not precisely the same, though doubtless both act on the same principle in 
arresting the paroxysms of the fever. The bark is destitute of a diaphoretic 
property, and acts as an astringent and tonic. A greater reduction of the 
powers of the system is, therefore, necessary for the successful administration 
of that medicine than for the sulphate prepared from it ; while, on the other 
hand, the bark is best adapted to cases in which the vital energies are seriously 
impaired. If to these variations we add that, when the stomach is irritable, 
the sulphate may be retained, but the bark thrown up, we have before us all 
the data necessary to a practical estimate of the relative value of the two medi- 
cines in the present disease. ;; 

In the inflammatory forms of intermittent fever, Dr. D. considers it im- 
proper to administer the quinia until the febrile excitement has been reduced 
by venesection and other antiphlogistic remedies; which preparatory treat- 
ment is still more important, in his estimation, when the case is complicated 
with inflammation of either of the internal organs. 

The chapter on the general history, symptomatology, pathology, and treat- 
ment of malignant intermittent fever, will be read with interest and profit. 
Dr. Drake considers this variety of the disease to be little else than the cold 
stage of an ordinary intermittent, deepened and prolonged. 

"The innervation is scathed, the circulation is enfeebled; the blood, largely 
retained from the more external parts, circulates with difficulty through the in- 
ternal or visceral system, which is rendered plethoric, and the great organs, 
as the stomach, spleen, liver, lungs, heart, and brain, are, respectively liable to 
pernicious engorgements or obstructions, greatly increasing the danger. A 
failure in the function of respiration, in the co-operative action of the brain, and 
in the projectile "power of the heart, combine to diminish the aeration of the 
blood ; which, deteriorated in its constitution, contributes still further to sink 
the powers of life. This condition of the respiratory function diminishes the 
heat of the body, which is moreover reduced by the failure of the calorific 
function of the skin, from the combined lesions of the nervous and circulatory 
systems, while the ready transudation, which the relaxed integument permits, 
of the serous portion of the blood, and the copious exhalation which takes place, 

1850.] Drake on Diseases of Mississippi Yalley. 119 

accelerate the cooling. Thus the patient dies under the combined influence of 
depression of the vital forces, and that consequential accidental or engorgement 
of some organ which has procured for this fever the epithet congestive. Or, 
should a partial reaction occur — should he survive two or three paroxysms to 
expire in a fourth or fifth, as occasionally happens, a low inflammation may be 
superadded to passive hyperemia, in the organs most capable of reaction, while 
others remain torpid and, perhaps, engorged." 

In the simple and inflammatory varieties of remittent fever, Dr. D's practice 
is, after blood-letting, at the onset of the disease, followed, in cases attended 
by the signs of gastric and biliary disorder, by a mercurial cathartic, to com- 
mence immediately with the liberal use of the quinia — ten grains of the sul- 
phate, with one or two of opium, and, if none has been already given, ten 
grains of calomel. 

"The results which may be expected are sleep and perspiration, with a full, 
slow, and soft pulse. In the latter part of the following night, the dose of 
quinine must be repeated, with or without the other medicines, and again re- 
peated about noon the next day. It does not follow that the patient will not 
at that time have some degree of thirst, pain in the head or back, and increase 
of pulse; but his warm perspiration will continue. In this exacerbation an 
injection may be administered, if he had not been previously purged, or he may 
be bled again. At bedtime a fourth dose of the quinine, with an equal quan- 
tity of Dover's powder, should be taken ; and another portion of quinine should 
be exhibited early the next morning. If he had not been freely purged at the 
beginning, he may now take a stimulating cathartic ; but, if possible, should 
use the pan, and not leave his bed during the operation. In the early part of 
the following night he must repeat the quinine and Dover's powder, after which 
a repetition will scarcely be required. He ought, however, to keep in bed for 
two or three days longer; a gentle diaphoresis should be kept up, and the 
healthy action of the liver restored, by small doses of the blue pill and quinine, 
with a gentle opiate at night." 

The chapter on malignant remittent fever demands a careful perusal — it is 
replete with valuable practical remarks. 

The tenth chapter is devoted to the pathological anatomy and consequences 
of autumnal fever. 

From the first section, we quote the following remarks in reference to the 
mortality of the disease : — 

"A simple intermittent fever, even when left to take its course, rarely, per- 
haps never, proves directly fatal ; but it may derange the structure of some 
organ, or generate a kind of cachexia or spansemia, from which, as pathologi- 
cal causes, other and, at last, fatal consequences may follow." 

" Inflammatory intermittents demand the interposition of art to bring them 
to a favourable termination. Left to themselves, it is true, they will not in 
general destroy life immediately ; but the persisting inflammation of some vital 
organ may, at last, give a fatal termination, Under a well-known treatment, 
however, such cases may generally be cured. 

"It is otherwise with inflammatory remittents, which, in their advanced 
stages, often take Qn a typhus character and prove fatal. Of the proportion 
who die, it is impossible to speak. I have proposed to our brethren in various 
places to send me returns of the annual relative mortality from the different 
diseases occurring in their practice ; but the amount of material thus obtained 
is, as yet, too small to justify its presentation. I do not believe that simple 
and inflammatory remittents are more fatal in the south than in higher lati- 
tudes ; but the mortality from them is greater, because they occur more fre- 

"Malignant intermittent fever is always mortal when not arrested by art; 
and many die from it every autumn, its true character not being perceived in 
time, or the patient residing beyond the range of enlightened medical practice. 
Where this variety prevails, therefore, it constitutes, in autumn, the chief outlet 

120 Review. [July 

of human life ; notwithstanding a successful mode of treatment has been dis- 

"Malignant remittents are not so common as intermittents, but more difficult 
of cure, and, therefore, much oftener fatal. 

" In traversing the interior mlley, from north to south, we find that the num- 
ber of deaths from autumnal fever, as compared with the number from all other 
diseases, constantly increases. In the higher latitudes, the prevalence of this 
fever is less, the variety of diseases greater, and the deaths distributed more 
equally through the year. In the south, the chief mortality is from July to 
November ; though in certain winters, large numbers die of pneumonia, en- 
grafted on constitutions enfeebled and deranged by the insalubrious air of the 
previous autumn ; still it may be affirmed that, below the thirty-third parallel, 
the inhabitants enjoy more uninterrupted health, for eight months of the year, 
than in any other part of the valley ; and hence it was not without reason that 
the distinguished Professor Caldwell, several years since, attempted to show 
that, taking the year round, New Orleans was the healthiest city on the conti- 

Dr. Drake's remarks on the pathological anatomy of intermittent fever are 
not without interest. He has, however, added little, if anything, to our 
previous knowledge in respect to it. His conclusions are based on too slender 
a series of observations, many of them very loosely reported, to render them 
of any particular value. Nor is his account of the pathological appearances 
peculiar to remittent fever more full or satisfactory. 

The consequences of autumnal fever Dr. D. treats of under the head of, 
1st. The chronic action of the cause by which he is inclined to believe vari- 
ous diseases may be generated, or, at least, diatheses and predispositions to 
them. 2d. Inflammation, suppuration, and enlargement of the spleen. 3d. 
Diseases of the liver. 4th. Dropsy. And 5th, periodical neuralgia. The 
pathology and management of each of which are treated of at some length. 

Our first intention was to have given a short general notice of this first 
volume of the work of Dr. Drake, believing it to be one, the full value of 
which is not to be fully appreciated excepting after a careful study of the several 
books, parts, chapters, and sections in which the materials it presents, in rela- 
tion to the etiology, character, pathology, and treatment of the diseases of the 
Interior Valley, are distributed. We have been led into a more extended, 
though still very imperfect and superficial, review of the volume, from the deep 
interest we felt in its teachings, as we proceeded in our perusal of it. It is 
truly a most valuable addition to our native medical literature, and we earnestly 
hope that the author will be spared to complete the work according to the 
original plan. That he will be encouraged to do this, at an early period, by 
the favourable reception given to the present volume, we cannot for a moment 

No attempt has been made to criticise the several views advanced by the 
author : although we cannot assent to the accuracy of all his pathological con- 
clusions, these are of such minor importance compared with the vast mass of 
valuable material he has, with untiring industry and great skill, collected and 
arranged for our use, as well as the general soundness of all his practical de- 
ductions, that we have felt no inclination to contest with him a few speculative 
opinions, which, even if unsound, scarcely detract from the value of his facts 
or the accuracy of his protracted and repeated observations. 

We commend the work to the patronage of the physicians of the United 
States. Although its subjects may be supposed to interest chiefly those of the 
Great Interior Valley, still it contains much equally interesting and instruc- 
tive to the great body of the profession throughout every portion of our 
country. D. F, C, 

1850.] 121 


Art. XVII. — The Microscopic Anatomy of the Human Body in Health and Dis~ 
ease. Illustrated with numerous drawings in colour. By Arthur Hill Has- 
sall, M. B., author of a " History of the British Freshwater Algae," Fellow 
of the Linnsean Society, &c. &c. In two volumes, 8vo. : London, 1849. 

The short time which has elapsed since Schwann opened a new era in phy- 
siological science, by presenting to the world his theory of the organic cell as 
the universal type of organization, has been unusually prolific in contributions 
to Microscopic Anatomy. These are distributed among the various periodicals, 
works on physiology, etc., in different languages; and the above is the title of 
the first successful attempt by an English author to embody the whole in a com- 
plete treatise devoted to the subject. But the work does not entirely rest upon 
the labour of others ; Mr. Hassall has gone over the whole ground of histology 
during " three years of more or less constant labour," as he observes in the 
preface, and " has but in a few instances written upon a subject without pre- 
vious investigation." The work is exceedingly well got up, and apparently at 
considerable expense ; the second volume is an atlas of sixty-nine lithographed 
plates, with over three hundred figures, most of them coloured, and with but 
nine exceptions, drawn directly from nature, of which they appear in most 
cases to be very faithful representations. 

In the plan of the work, Mr. H. divides the structure of the human body into 
fluids and solids. The former are subdivided into the organized and the unor- 
ganized. To the organized belong the lymph, blood, &c. ; to the unorganized, 
the saliva, bile, &c. To the consideration of the first he devotes more than 
one-third of the first volume, and they are treated of in a masterly manner, in 
the pathological as well as the healthy condition. 

In the article upon the blood, the author adds an additional consideration to 
those usually given in reference to the formation of the inflammatory crust. He 
says: "The greater the density of the blood, the longer would the globules take 
to subside in that fluid ; and the less its density, the shorter would that period 
be. Now, inflammatory blood is usually of high density, while with that of 
feeble vitality, the reverse obtains. Thus, were it not for the fact that in blood 
in the first state coagulation is slow, and in the second quick, the blood of 
weak vital power would be that in which, a priori, we should expect to see 
the buffy coat most frequently formed ; but the much greater rapidity in the 
coagulation of the blood more than counterbalances the effect of density. 

" The blood, then, may be so dense, that although at the same time it coagu- 
lates very slowly, yet no inflammatory crust be formed, the patient from whom 
the blood is extracted labouring all the while under severe inflammation. An 
ignorance of this fact has been the source of many great and perhaps fatal 
errors, on the part of those physicians who have been used to regard the pre- 
sence of the buffy coat as an undoubted evidence of the existence of inflamma- 
tion, and its absence as indicating immunity therefrom. It has been remarked 
that, in the first bleedings of pneumonic patients, the blood often wants the 
buffy coat: this is attributed to its greater density, and which is found to 
diminish with each succeeding abstraction of blood; so that, if inflammation be 
present, the characteristic coat is usually apparent also after the second 

" The conditions, then, favourable to the formation of the buffy coat, are a 
mean density of the blood, slow coagulation; excess of fibrin, and increased 
disposition to adherence on the part of the red corpuscles. 

" Other circumstances doubtless exist which in a minor degree affect the for- 

122 Bibliographical Notices. [July 

mation of the crust: such as the density of the globules, and the qualities of the 
fibrin itself. Into these it is unnecessary to enter, as they do not vitiate the 
accuracy of the general statements." 

The author gives an account of a very remarkable observation which he made, 
appearing to prove that the capillary circulation is in a great measure inde- 
pendent of vital influences (so called), and is mainly due to physical agencies. 
A detached portion of the tongue of a frog, submitted to microscopic examina- 
tion, exhibited a quite active circulation for some hours. This phenomenon was 
no doubt the result of endosmosis and exosmosis, which continually take place 
in the living body, between the circulating fluids and the fluid contents of the 
structural elements of the tissues. 

In treating of inflammation, he says: "The proximate cause of inflammation 
consists in an abnormal accumulation of the corpuscles of the blood in the 
minute capillary vessels, and which accumulation we perceive must inevitably 
impede the function of the part in which the vessels are thus surcharged, alter 
its structure, and finally tend to a sympathetic disturbance of the entire eco- 
nomy. For this discovery, we are indebted to the microscope. It will thus be 
seen that some of the ancient hypotheses in reference to the proximate cause 
of inflammation were not so very far wrong, and that most of them recognize 
the fact that it is the capillary vessels and blood corpuscles which are mainly 
concerned in the production of the phenomena of inflammation. " 

The pathological conditions of the blood are fully treated of, and form an 
important part of the work. A chapter is also added on " The importance of 
a Microscopic Examination of the Blood in Criminal Cases," which contains 
many useful hints in medical jurisprudence. 

Mucous globules Mr. H. conceives to be "young epithelial scales, as are also 
the colourless globules of the blood; they both have a like structure and a cor- 
responding function to perform, but they have a different origin ; thus the mu- 
cous globules are developed externally to the lymphatics and blood-vessels, 
while the colourless blood-corpuscles are formed within those vessels." And 
further, he adds, " Pus corpuscles I conceive to be identical with mucous cor- 
puscles, and these again are to be regarded as representing an early stage in 
the development of epithelial scales." 

In answer to the much disputed question as to the distinction between mu- 
cous and pus, he says — " Although it is impossible to discriminate between 
true mucus and pus by means of the microscope in a positive manner, we are 
yet enabled to distinguish with that instrument false mucus from pus, because 
in this mucus the corpuscles exist in their fully developed form of tesselate epi- 
thelium; now this power of discrimination is not without importance, as will 
be perceived immediately. 

"Many persons on arising in the morning are in the habit of expectorating 
-more or less of a substance bearing much resemblance to pus. This habitual 
occurrence is not unfrequently a source of much uneasiness, not merely to the 
person the subject of it, but also to his medical adviser whom he is led to con- 
sult upon it. 

"Now, in such cases as these it is often in our power to dispel the anxiety of 
our patient and our own at the same time ; for the solid constituents of such 
sputa are frequently found to consist almost entirely of epithelial cells, in which 
case we may safely pronounce that they are not purulent; if, on the contrary, 
the sputa contain only globules, the evidence which this fact would furnish, 
although apparently, and indeed most probably, unfavourable, would still be 
but of a doubtful nature. 

" Again, the microscope will frequently determine the nature of a suspected 
fluid, by indicating in it the existence of shreds of cellular tissue, muscular 
fibrillcC, and a variety of other organisms which enter into the formation of the 
human body ; and by the presence of one or more of which, not merely the 
nature of the puriform matter may be ascertained, but also the locality from 
which the pus had itself proceeded." 

Considerable space is devoted to the consideration of the human milk in its 
varied conditions of health and disease, to which we refer the reader for much 
valuable information. 

1850.] Maclise's Surgical Anatomy. 123 

In the part of the work on the solids, the author notices a new position in 
which he has discovered the ciliated epithelium to exist, viz., in the convolutions 
of the epididymis. 

His investigations also confirm the view of Schwann, that the Purkinjean 
corpuscle of bone is a complete cell, and the canaliculi prolongations of the 
cell wall. 

In reference to the almost universal opinion of later physiologists, that the 
nerves of muscles form loops, which either join other neighbouring loops, or 
else return into themselves, Mr. II. observes : " I have never seen the nerves 
terminating in muscle in the manner indicated ; not, however, that I doubt the 
fact of their doing so, because such a mode of termination is common to nerves ; 
but would simply infer from this, that the loop-like arrangement is neither very 
general nor very obvious. 

' ; According, then, to the latest physiologists, nerves, strictly speaking, really 
have no termination whatever in muscles : an opinion the accuracy of which is 
more than doubtful. 

" I find that the nerves, after branching in a dichotomous manner, have a real 
termination, and that from time to time certain tubules leave the main trunks, 
and end in the formation of elongated and ganglioniform organs situated be- 
tween the fibres of muscle." 

In the medullary matter of the cerebrum, cerebellum, and spinal marrow, 
the author has discovered intermingled with the tubular structure, globular 
bodies, which are perfectly independent of the oleo-albuminous matter of the 
interior of the tubules. These bodies are very numerous, invariably present, 
and vary in size from the diameter of the tubuli to ten times the diameter of 
the same. Whether they are true cells, he failed to determine. 

According to the investigations of Mr. II., the air-cells of the lungs freely 
communicate, and are lined by ciliated, cylindrical epithelia. 

In regard to the biliary ducts terminating in a lobular biliary plexus, the 
author presumes it to be concluded that no such an arrangement exists, and 
bases his views upon those of Dr. Hanfield Jones, whose coarse mode of inves- 
tigating the structure was followed by Mr. II. with, of course, the same result. 
"If a branch of the hepatic duct be taken up with the forceps, it may, by deli- 
cate manipulation, be dissected out from the surrounding parenchymatous tis- 
sue. A branch thus prepared, when placed under the microscope, will be seen 
to be composed of numerous ramified biliary ducts of various sizes : the extre- 
mities of the majority of these are even broken off; but several are evidently 
entire, and these are rounded." We cannot understand how the most deli- 
cate manipulation of the scalpel and forceps is able to obtain anything further 
than some of the smaller trunks of the biliary ducts, and we can conceive of no 
better mode of obtaining a true idea of the lobular structure, than by injecting 
the capillary vessels to avoid error, and then examining thin sections with a 
moderately high power of the microscope. 

Much space has been devoted to the consideration of the pathological condi- 
tions of the kidney, principally derived from the researches of Toynbee, John- 
son, Simon, and Gairdner. 

Without examining further into the merits of the work, we recommend it to 
students and others as being the best epitome of the microscopic anatomy of 
the human body in the English language. J. L. 

Art. XVIII. — Surgical Anatomy, by Joseph Maclise, Surgeon: with coloured 
plates. Part Second. Philadelphia, Lea & Blanchard, 1850. 

In the number of this journal for January last, we noticed the first part of 
Mr. Maclise's book, and acknowledged in terms of merited commendation the 
excellence of the work. The style of the author was sometimes rather laboured, 
and wanting in that transparency which is so particularly desirable in a 
scientific treatise ; but we felt unwilling to call attention to this defect, because 

124 Bibliographical Notices. [July 

the instructions were so good. The second part is now published, and in it we 
are happy to observe much less of the fault alluded to, with the same careful 
description and accurate delineation which pleased us so much in the first. 

The preceding fasciculus concluded with an explanation of the surgical ana- 
tomy of the forearm ; the present is devoted to the consideration of the wrist 
and hand ; to some points of the anatomy of the neck and head, which were 
not previously noticed; to the thoracic and abdominal cavities, and to the in- 
guinofemoral region. It will thus be perceived that the author has here taken 
upon himself a very arduous task; one which demands for its successful 
accomplishment great familiarity with some of the most important and intri- 
cate points in the whole domain of surgical anatomy, and one which, if well 
performed, cannot fail to be productive of lasting benefit to the student. A 
more detailed enumeration of the contents of the part before us will assist in 
the determination of its value. 

The first three plates, Nos. 17, 18, and 19, exhibit the anatomy of the wrist 
and hand. In the text associated with them, these parts are very well described, 
and the items of chief interest in a surgical point of view are adverted to. 
These are the relative situations of the vessels and nerves to each other, to the 
muscles and to the bony structure ; the free anastomosis of the arteries, and 
the occasional irregularities in their origin and distribution, together with the 
inference desirable from these circumstances, with regard to the difficulty of 
arresting hemorrhage from these vessels, and the mode by which this accident 
may be controlled, particularly in the event of a wound of the palmar arteries. 

Plates 20 and 21 present views of "the relative position of the cranial, nasal, 
oral and pharyngeal cavities, &c ;" and the general and particular conforma- 
tions of these parts are explained in the commentary. The author takes a com- 
prehensive view of the subject, points out how, from continuity of structure, in 
some instances, disease and injury at one point affect other parts; and how, 
from dissimilarity of structure in other instances, the progress of disease is 
naturally limited. The particular topics of surgical interest relate to the occur- 
rence of fracture of the cranium, and the peculiarities of this accident from the 
shape and structure of the cranial bones; the points to be avoided in the 
application of the trephine to the skull ; the conformation of the cavities of the 
nose, mouth, and pharynx, together with hints as to the introduction of the 
catheter into the Eustachian tube, the nasal duct, and the stomach. 

The next five plates, 22 to 26, inclusive, should be studied in connection with 
the first and second of the preceding number. They form, together with the 
author's remarks thereon, a very complete survey of the regional anatomy 
of the thoracic and abdominal cavities ; and we feel confident that the excel- 
lence of this part of the treatise will be acknowledged by every attentive reader. 

The first two sections describe the relative position of the organs of the chest 
and abdomen. Mr. Maclise calls attention to the fact that the line of demar- 
cation between these two cavities is not precisely determined. "In birds and 
many reptiles, e. g. the costal arches enclose the common thoracico-abclominal 
region, as if it were a common pulmonary region. In fishes, the costal arches 
enclose the thoracico-abdominal region just as if it were a common abdominal 
region." In man, however, the ribs are in relation with the thoracic organs only, 
and, together with the interposed diaphragm, isolate the thorax as a region from 
the abdomen. Nevertheless, this membranous septum is constantly changing 
its position under the influence of the physiological actions which take place in 
the organs contained in these cavities, and of many diseased conditions to 
which they are respectively liable. Hence, the thoracic cannot maintain any 
fixed relative position to the abdominal viscera, neither is the local relation of 
the different organs of either of these cavities to each other invariable. These 
facts a,re of importance to the surgeon and to the physician with reference to 
the diagnosis of injuries and diseases; and Mr. Maclise devotes several pages 
to the discussion of this subject, not only in general terms, but with allusions 
to many of the particular conditions upon which these changes of relation 

The twenty-fourth plate and its commentary display " the relations of the 
principal blood-vessels to the viscera of the thoracico-abdominal cavity," together 

1850.] Maciise's Surgical Anatomy. 125 

with a few suggestions as to the diagnosis and etiology of some of the diseased 
conditions of the organs therein contained. 

In the next plate is presented a view of the principal blood-vessels of the 
thorax and abdomen, with reference to their relation to the osseous skeleton. 
In the text, the author points out the analogy which exists between the con- 
figuration of the bony framework of the chest and that of the great arterial 
trunk with its outspringing branches, and contends that the individual blood- 
vessels, particularly the arteries, possess forms as characteristic of their situa- 
tion and mode of distribution as do the separate pieces of the skeleton, and 
may just as readily be assigned " a local habitation and a name." He also 
demonstrates the general correspondence between the superior and inferior 
great branches of the aorta; a correspondence which is not only interesting to 
the philosophical anatomist as showing a certain uniformity of type, but is 
important to the practical surgeon as reminding him of the possibility of such 
an arrangement in any individual case, and of the necessity of preparing for 
it in the event of an operation. Some other departures from the general type 
of the aorta are alluded to. Such digressions from the hard-worn highway of 
anatomical investigation as are met with in this chapter, "serve to lighten the 
dry and weary detail of descriptive anatomy, at the same time that they lead 
directly to points of practical import ;" they are like the grassy by-paths which 
allure the traveller from the dusty turnpike to the fields and shaded spring — 
they are always welcome. 

The following chapter comes as a very natural sequent to the several sections 
which precede it, and treats of "the relation of the internal parts to the ex- 
ternal surface of the body." The author remarks that "the abnormal condi- 
tions of the surface become at once apparent to our senses; but those diseased 
conditions which concern the internal organs require no ordinary exercise of 
judgment to discover them." The object of this chapter is to show which of 
the internal organs are most liable to become deviated from their normal rela- 
tionship with certain points upon the surface of the body, which ordinarily 
serve to mark their position ; how this deviation is occasioned, and how, when 
an operation is called for, such organs may best be reached in their abnormal 

"The surgical dissection of the superficial blood-vessels, &c, of the inguino- 
femoral region," forms the subject of the succeeding section and plate. 

The anatomy of hernia is, or was, the bugbear of the young student. We well 
remember the dread which the mere allusion to it excited in our mind. It pre- 
sented such a wilderness of names appended to arbitrary divisions, often of one 
and the same tissue; and there were such seeming confusion and discord in 
the opinions of distinguished anatomists and surgeons respecting the several 
parts involved, that we felt impelled to imitate the conduct of all pious pilgrims, 
whose journey led them through forests, haunted by goblins and demons ; we 
resolutely closed our eyes and our ears, and prayed to be preserved from all 
knowledge of such " sights and sounds unholy." Evidently the subject has 
been studied "not wisely, but too well;" as if it were desirable not to render 
the matter plain and easily comprehended, but to see how much could be made 
of it. A simplified description of the anatomy of the region concerned, such 
as is presented by Mr. Maclise, will, therefore, we doubt not, be acceptable to all. 
He first touches upon the artificial difficulties which have been thrown around 
the subject of hernia; passes then to a brief statement of the causes of the 
accident ; and reviews its nomenclature, the chief situations at which it occurs, 
with the reasons for such selections, and then demonstrates the superficial 
anatomy of the inguinofemoral region. He thus considers the inguinal and 
femoral regions, "not separately, but as a relationary whole; for as both 
regions are blended together by structures which are common to both, so do 
the hernise which are described as being proper to either region, occur in 
such close connection, as a*t times to render it very difficult to distinguish 
between them." The chapter is written with unusual clearness, and there 
is an evident desire on the part of the author to simplify the subject, and to make 
it easily understood; and the drawing of the parts is admirably executed 
and well illustrates the text. The following extract will serve to exhibit the 
No. XXXIX.— July, 1850. 9 

126 Bibliographical Notices. [July 

aim and spirit of the author. He says, "the practitioner who would arm his 
judgment with the knowledge of a broad fact or principle, should not allow 
his serious attention to be diverted by a pursuit after any useless and trifling 
details ; for not only are they unallied to the stern requirements of surgical 
skill, but they serve to depose it from the rank and roll of the sciences. 
Whilst operating for the reduction of inguinal hernia by the taxis or the bis- 
toury, who is there that feels anxiety concerning the origin or the distinctive- 
ness of the "spermatic fascia ?" Or, knowing it to be present, who concerns 
himself about the better propriety of naming it "tunica vaginalis communis," 
"tunique fibreuse du cordon spermatique," "fascia cremasterica," or "tunica 

The same subject is continued in the next and last chapter of the present 
number, which is entitled " the surgical dissection of the first, second, third, and 
fourth layers of the inguinal region, in connection with those of the thigh ;" 
and the text is accompanied by two excellent plates. The clearness of exposi- 
tion and the avoidance of all prolix and unnecessary detail which characterize 
the preceding chapter, equally mark this. It is very well adapted both to 
serve as a guide to the student in dissecting the parts described, and to refresh 
the mind of the operator, who is about to attempt the relief of a strangulated 
hernia ; and this, we apprehend, is all that can be desired or expected. 

In short, the satisfaction which the perusal of the first part of Mr. Maclise's 
book afforded us, is renewed in this, both with regard to the drawings and the 
commentary. And we cannot but feel assured, from these specimens, that the 
ensuing numbers will prove equally valuable in furnishing a safe and practical 
treatise on the surgical anatomy of the regions which remain to be described. 

F. W. S. 

Art. XIX. — Essays on the Puerperal Fever, and other Diseases peculiar to Women, 
selected from the Writings of British Authors previous to the close of the 
Eighteenth Century, by request of the Sydenham Society. Edited by Fleetwood 
Churchill, M.D., M. R. I. A., &c. &c. Philadelphia, Lea & Blanchard, 
1850 : 8vo. pp. 464. 

The present volume comprises the essays of Denman, Hulme, Leake, Charles 
White, Kirkland, Butter, Joseph and John Clarke, and Gordon on Puerperal 
Fever ; Dr. John Clarke's " Directions for the Management of Pregnancy and 
Labour, with a View to Prevent Disease" — his remarks on " Retroversion of 
the Uterus, Milk Fever, Inflammation and Suppuration of the Breasts;" 
Fothergill on the " Management proper at the Cessation of the Menses ;" Mac- 
bride's " Cases of Tumefaction of the Labium after Delivery ;" Clarke on 
" Cauliflower Excrescence of the Os Uteri," and his two cases of Tumour of 
the Uterus, with Dr. Denman's Account of an Excrescence from the Womb. 

To these papers Dr. Churchill has appended notes, embodying whatever in- 
formation has been laid before the profession since their authors' time. He 
has also prefixed to the essays on puerperal fever, which occupy the larger por- 
tion of the volume, an interesting historical sketch of the principal epidemics 
of that disease. 

The whole forms a very valuable collection of papers by professional writers 
of eminence, on some of the most important accidents to which the puerperal 
female is liable ; and although on most of these we have more recent treatises 
and monographs, in which the facts recorded by preceding writers have been 
confirmed and amplified, and many of their errors in pathology and practice 
pointed out and corrected, still the essays before us are replete with matters 
calculated to interest and instruct the physicians of the present day. With 
the opinions and observations which they presenf, no one should, at least, be 
ignorant, who would lay claim to the character of a well informed practitioner. 

On puerperal fever, a disease with the true pathology and proper treatment — 
the etiology and prevention — of which we, unfortunately, as yet know but 
little, if anything, the tracts in the present volume have been selected so as to 

1850.] Churchill's Essays on the Diseases peculiar to Women. 127 

give the experience of the writers in particular epidemics, including purposely 
those whose descriptions and opinions differ, affording thus an excellent prac- 
tical illustration of the variations presented in the character of the fever in 
its prevalence at different periods and in distinct localities. 

The introductory discourse of Dr. Churchill does not consist of a bare enu- 
meration of the several epidemics of puerperal fever that have been recorded 
from the earlier periods of medical history to the present time. The accounts 
of the several occurrences of the disease being accompanied with an interest- 
ing abstract of the observations and opinions of the writers from whom those 
accounts are derived, whenever these observations and opinions are of sufficient 
importance to merit especial notice, either from the professional standing of the 
author, their direct bearing upon the pathology and therapeutics of the disease, 
or its peculiar character in the particular epidemics upon which they are based. 

The discourse of Dr. Churchill concludes with some judicious remarks on the 
pathology of puerperal fever, which he offers "rather as suggestions to induce 
his readers to follow up the subject, than as absolute inferences." 

His first remark is, that some special connection would appear to exist be- 
tween the epidemics of puerperal fever and lying-in-hospitals. He does not 
mean exactly to assert that these epidemics always originate with and are kept 
up by these hospitals ; but refers to the fact that we have no record of any epi- 
demic independent of them in early times. 

" No doubt the disease has since then been observed in private practice in 
London, Edinburgh, Sunderland, Leeds, &c. &c, but its extent in these cases 
is, after all, comparatively limited, except in very sickly times, and it is often 
confined chiefly to the practice of a few individuals." 

"2. Perhaps the most universal fact connected with puerperal fever is the 
presence of local disease. In almost all cases of the epidemic, where an oppor- 
tunity of ascertaining has been allowed, local lesions of some kind or other 
have been found, and even when this opportunity was denied, but little doubt 
existed in the mind of the practitioner that such existed. It seems very pro- 
bable that, in many cases where the local disease seemed but slight, there 
would now be found very serious and important morbid changes ; for we know 
that a patient may die of inflammation of the uterine veins or lymphatics, with 
very obscure symptoms, and without either enlargement or very obvious ten- 
derness of the uterus, and that these morbid lesions may be overlooked, if the 
examination be hasty and superficial." 

According to Dr. Lee, puerperal fever invariably depends upon some local 
disease of the uterine organs, attended, in fatal cases, with a disorganization of 
their different textures. Dr. Churchill formerly entertained a similar view — its 
correctness he has, however, latterly seen reason to doubt. 

" Though," he remarks, "I would wish to express myself cautiously and 
guardedly, I must honestly avow that, whilst I fully admit the existence of 
local disease, I do think that epidemic puerperal fever is something more than 
that, although I may not be able to define what it is." 

This supposition is based on several grounds. 1st. The very remarkable 
variety of opinions as to the nature of the disease — this being hardly recon- 
cilable with the notion of a simple local inflammation. 2dly. The diversity in 
the prevailing character of different epidemics, and in the plans of treatment 
recommended for the arrest of the disease ; and lastly, if any one will compare 
a case of simple inflammation of the womb or peritoneum, in childbed, with a 
case of epidemic puerperal fever, the symptoms and course of the two affections, 
and the effects of remedies in each, Dr. C. does not think that a doubt will re- 
main upon his mind that, although the latter is a local disease, it is not exclu- 
sively so. 

After examining the peculiar effects of uterine phlebitis, and showing that 
it produces a deterioration of the blood, and remarking that the symptoms 
which Mr. Guthrie describes as characteristic of irritative phlebitis are very 
like those of puerperal fever, Dr. C. goes on to state that 

" Puerperal fever prevails most during the winter or spring months, and in 
moist and cold weather, or with alternations of cold and warm moist weather." 
" It may be of importance, therefore, to consider what epidemic diseases are 

128 Bibliographical Notices. [July 

concurrent at such seasons with puerperal fever. There are three which appear 
to be so especially: bowel complaints (or gastro-enteritis), typhus fever, and 
erysipelas. The evidence in support of this statement is so abundant, that to 
adduce it would be to quote almost every writer on the subject." " Nay, it 
would appear from the statements of Dr. Labatt and Dr. Collins, that typhus 
fever, occurring in a patient in a lying-in-ward, is capable of originating puer- 
peral fever. Now, I believe that there is little doubt at present, that in fever 
the composition of the blood is changed, and that in typhus fever the deteriora- 
tion has reached its maximum. 

" From the concurrence of puerperal fever and erysipelas as an epidemic, it 
has been asserted by many, and with great probability, that they are essentially 
the same disease — certainly they prevail during the same atmospheric condi- 
tion, exhibit often the same general symptoms, and Mr. Nunnelly asserts may 
reproduce each other. Dr. Hutchinson and others have seen the two diseases 
in the same patients, and I think there is evidence to show that the infants of 
women attacked by puerperal fever are very liable to attacks of erysipelas or 
diffuse inflammation. 

"Now, one peculiarity of erysipelas, in which Mr. Nunnelly states it resem- 
bles puerperal fever, is the disposition to the formation of pus in various parts 
of the body, and he admits the probable consequent deterioration of the blood." 

" So far, then, we find that the same seasons give rise to certain diseases 
(puerperal fever, continued and typhus fever, and erysipelas), that they prevail 
at the same time epidemically, and, as an epidemic, take on the same type, and 
appear capable either of giving rise one to the other or of co-existing. Now, 
perhaps (to use an arithmetical expression), if we could subtract the local pecu- 
liarities of puerperal fever from that which it has in common with the others, 
we should arrive at the object of our search. Can it be that some change in 
the composition of the blood is this element V 

After noticing the opinions given by various authors in relation to the condi- 
tion of the blood in puerperal fever, Dr. C. remarks : — 

"I should be very sorry to come to any hasty conclusion on so difficult a subject, 
but it appears possible, at least, that the general element, which constitutes the 
difference between epidemic puerperal fever and simple inflammation of the 
uterus and peritoneum, may be some deterioration of the blood, depending 
either upon atmospheric malaria from without, or absorption of some noxious 
matter within the body. Whether further researches may prove this to be true 
or not, I cannot but agree with Mr. Moore that, ' in puerperal fever, as in 
typhus, cholera, and other epidemic and contagious diseases, which seem pro- 
perly to belong to the class neuroses, there is, besides that of inflammatory 
action, another element, unknown, but which has an essential influence upon 
the intercurrent phlegmasia arising in their course, and which may yield at 
one point only to appear at another/ " 

On the important questions, is puerperal fever contagious ? and, can it be 
conveyed by a third party, in health, from a person labouring under it, to 
another person in childbed ? Dr. C, after adducing the opinions of the leading 
authorities, and some of the more prominent facts having a bearing directly upon 
the subject, remarks : — 

" The evidence and proofs thus adduced are of extreme importance, and I 
fear we must conclude, however reluctantly, in favour, not merely of the conta- 
giousness of puerperal fever, but of the possibility of its contagion being car- 
ried by an intermediate party. This makes the practice of midwifery doubly 
distressing during the prevalence of an epidemic, and ought deeply to impress 
us with the necessity of the utmost care and caution/' D. F. C. 

1850.] Hamilton's Essay on Syphilitic Sarcocele. 129 

Art. XX. — Essay on Syphilitic Sarcocele. By John Hamilton, Surgeon to the 
Richmond Hospital, Dublin, pp. 40, with two colored lithographs. Dublin, 

Hospital physicians owe to the profession an important duty. Possessed of 
ampler opportunities of investigating disease than their brethren in private 
practice, and being thus in the way of acquiring superior skill and more ex- 
tended information, it must reasonably be expected of them that they shall 
contribute most largely to the progress of medical science. They are our 
watchmen, and should inform us of the changes which pass over our intellect- 
ual heavens ; of the gathering darkness, the threatening storm, the approach 
and the advent of light. Any tidings from such a source should command our 
attention and our respect. 

The essay whose title we have prefixed above, is the first of a contemplated 
series of papers by Mr. Hamilton, of Dublin, on the subject of syphilis. It is 
based upon examples of the disease, which have been observed by the author 
in the wards of the Richmond Hospital and elsewhere. 

We think it unfortunate for pathology that the old nomenclature of disease 
should still be so much retained as it is, and its links so newly riveted. Thus, 
Mr. Hamilton designates by the term " sarcocele," which conveys no definite 
meaning, either of the nature of the morbid process of which the testicle has 
been the subject or of the anatomical condition of the organ, a disease which 
we know to be chronic inflammation of the testicle: we would therefore prefer 
that it should be named accordingly, or that it should be designated by some 
appropriate synonyme, such as " chronic orchitis." 

The connection between chronic orchitis and syphilis is made apparent by 
the prior occurrence, in the same individual, of a primary change and subse- 
quent secondary and tertiary symptoms of the constitutional taint; and, to a 
certain degree, also, by the amenability of this local disease to the same treat- 
ment which cures the other manifestations of syphilitic infection. 

Mr. Hamilton makes two forms of chronic syphilitic orchitis, the simple and 
the tubercular. " The simple syphilitic sarcocele is met with in persons of healthy 
constitutions, and when accompanied, as it usually is, by other secondary 
symptoms, they are regular, well marked, and uncomplicated. As attendants 
on this form, I have seen the mottled, papular, pustular and scaly eruptions, 
and those dusky red spots, a little raised, and often a little scurfy, which were 
called by the older writers syphilitic blotches, iritis; the more healthy (if such 
a term is allowed) forms of inflammation of the bones and periosteum, and of 
ulcers in the throat" — p. 5. " The testicle will be found enlarged to the size of 
a lemon or of a turkey-egg, of an ovoid or pyriform shape, sometimes flattened 
at the sides ; either uniform on the surface or with the epididymis distinguish- 
able as an irregular ridge along the back ; hard, particularly in the situation of 
the epididymis ; heavy, with the integuments of the scrotum of a dusky red ; 
generally neither tender nor painful, excepting that the hanging weight causes 
a feeling of uneasiness in the loins and inside of the thighs." He has never 
observed the evening and nocturnal exacerbation of pain mentioned by most 
writers, as serving to assist in the diagnosis of the syphilitic from the ordinary 
form of chronic orchitis. He has found the disease to be limited generally to 
one testicle, and has never seen suppuration to occur. In common with other 
writers on the same subject, he calls attention to the frequent complication of 
hydrocele with this disease. 

"The tubercular syphilitic sarcocele," he says, "is much more common, and 
differs materially, both in local and constitutional symptoms, from the simple 
form. The testicle is enlarged from two to four times the natural size ; but the 
increase of size is generally not remarkable ; it is of very irregular shape, so 
that the ordinary form of the organ is often entirely lost, presenting, instead 
an uneven, hard, knotty mass, in which it is impossible to distinguish the body 
from the epididymis. At other times the irregularity is seen to arise from the 
enlarged and indurated epididymis, which gets of a great size, as compared to 
the body of the testicle, this remaining but little altered, and readily distin- 

130 Bibliographical Notices. [July 

guishable from it." The enlargement of the epididymis affects, usually, the 
upper globus ; there is seldom persistent pain or tenderness of the organ, and 
the progress of the disease is exceedingly slow; both testicles are, according to 
Mr. Hamilton, usually affected, although not equally. 

In the enumeration of the general symptoms which accompany this form of 
the local disease, the author is not, it seems to us, sufficiently explicit ; he enu- 
merates the concurrent diseases of the tissues, which depend upon the syphilitic 
contamination ; e. g., the soft cranial nodes, the caries of the bones, the corrod- 
ing ulcer of the throat, the " serpiginous, pustulo-crustaceous eruption," &c; 
but he makes no mention of the tubercular diathesis nor of any other local 
tubercular disease. Now, according to the high authority of Louis, tubercles 
are not found in any organ, after the age of eighteen years, without being also 
present in the lungs (in the last edition of his book on phthisis, only three 
examples to the contrary are recorded) ; yet Mr. Hamilton makes no mention 
of tubercular disease of the lungs being present in the cases of tubercular 
syphilitic orchitis which he adduces. Mr. Curling, on the other hand, who must 
be regarded as one of the highest authorities in this matter, lays it down as of 
the greatest importance, if not an essential element in the diagnosis of this form 
of orchitis, that there shall be some manifestation of the tubercular constitution 
in other organs of the body. In view of these considerations, therefore, while 
we admit fully the existence of the tuberculo-syphilitic orchitis, we must con- 
tend that Mr. Hamilton's cases are not convincing ; but that, if, as we have a 
right to suppose, the reports embody all the evidence bearing upon the question 
at issue, they are open to grave doubts as to the accuracy of his diagnosis. For, 
with but a single exception, they offer no strong cause for suspecting any tuber- 
cular complication, and in this case the patient had " extensive antero-posterior 
curvature of the spine ;" but if syphilis is the cause of caries of other bones, 
why may it not have occasioned, in this instance, the destruction of the bodies 
of the vertebrae ? 

The author's account of the anatomical condition of the testicle seems to us 
imperfect, and affords us another ground for questioning the correctness of his 
opinion in many of those cases which he calls tubercular, and which recovered 
so perfectly and so speedily. In the simple form of the disease, he says there is 
"a deposition of firm lymph of a pale yellowish colour into the interstitial cellular 
tissue external to the tubuli testis, as well, probably, as into the tubuli them- 
selves ;" and again — " I think this uniform deposition of firm, yellowish lymph 
is the pathological condition in those cases which I have named simple syphilitic 
sarcocele" — pp. 21, 22. In the other variety, he says — "There is one or more 
tubercles in the epididymis or body of the testicle ; they are of a yellowish colour, 
of a consistence rather less firm than that of coagulated lymph ; very small at 
first, they gradually enlarge, and, according to their duration, may vary in size 
from that of a hemp-seed or split-pea to that of a chestnut, or even larger. They 
have a well-marked cyst, which can, by careful dissection, be separated from 
the yellow, inorganic substance contained in them, and from the glandular sub- 
stance of the testicle in which they are imbedded ; the yellow substance within 
the cyst has sometimes a nucleated arrangement. It is proved to be inorganic 
(unorganized, he means, we have no doubt! ) by not receiving any injection, 
when the testicle has been most successfully injected"— pp. 23-4. This last 
circumstance is mentioned in contrast to the susceptibility of injection of the 
deposition observed in the other form of disease (vid. p. 22). Mr. Hamilton 
makes no allusion to having used the microscope in his examinations, and we 
therefore presume that he did not employ it. Now, by comparing his details 
of the post-mortem appearances with those given by other observers, e. g. Mr. 
Curling and Cruveilhier, we think it most probable that many, at least, of the 
cases which he cites as being tubercular were not really so, but were instances 
merely of the simple form of chronic syphilitic orchitis. Mr. Curling describes 
the deposits in the latter variety of the affection as being soft at first, gradually 
becoming firmer ; in some instances there being but a single deposit, in others 
several interspersed throughout the testis, sound portions intervening ; some- 
times these masses are very small, "like round, isolated, yellowish-grey bodies." 
This fibrin sometimes remains for a long period unorganized ; thus Mr. Curling 

1850.] Report on the Asiatic Cholera. 131 

says, "I have never succeeded in tracing vessels into it, but the vessels of the 
testis generally are enlarged, and appear more numerous than usual" (p. 317) ; 
of course, therefore, much stress cannot be laid upon the statement mentioned 
by Mr. Hamilton, that the tubercular may be distinguished from the fibrinous 
deposit, by the non-susceptibility of the former to the entrance of an injection. 

With respect to the treatment of the complaint, Mr. Hamilton thinks that the 
simple syphilitic orchitis is most readily cured by the internal and external 
employment of mercury ; and that the tubercular variety is best treated by a 
combination of the same method with the use also of iodide of potassium in- 
ternally. This treatment seems to have been eminently successful in Mr. 
Hamilton's cases, and, in those which he calls tubercular, more successful, we 
should think, than it is usually found to be. 

In conclusion, we think that the great fault of Mr. Hamilton's essay is, that 
he has not sufficiently compared his own observations and impressions with 
those of other writers ; and consequently he has, we fear, been sometimes led 

We shall be happy, however, to renew our acquaintance with him, on the 
appearance of his second essay. F. W. S. 

Art. XXI. — Report of the Committee of Internal Health on the Asiatic Cholera, 
together with a Report of the City Physician (Dr. Henry G. Clark) on the 
Cholera Hospital. Boston, 1849 : 8vo. pp. 182. 

In the epidemic of 1849, the first death from cholera at Boston took place on 
the 3d of June, and the last on the 13th of September. The disease continu- 
ing thus to prevail for nearly four months. We have no account of the entire 
number of cases that occurred during this period. The number of deaths 
reported at the register's office was 611 ; 160 were Americans, of whom 79 were 

The disease was chiefly confined to that portion of the population who were 
destitute of the common comforts of life, or whose habits were intemperate, 
and to those localities which were over-crowded with inhabitants, and deficient 
in ventilation, drainage, and cleanliness. Insulated instances of the disease 
were noticed in even the most salubrious portions of the city ; while, from the 
general influence of the epidemic cause of the cholera, no class of the com- 
munity were perfectly free ; still, the number of those in easy circumstances, 
who were actually attacked by the disease, were so small that they might almost 
be overlooked in the history of its visitation. 

The general opinion of the physicians of Boston seems to have been opposed 
to the contagious character of the disease. In the cholera hospital there were 
about twenty-five attendants, exclusive of medical officers, at different times, 
all of whom were more or less constantly in proximity to the subjects and their 
excretions, and many of them were only for a very few hours at a time out of 
the ward. Four physicians and four medical students were engaged in the 
duties of the hospital ; two of the latter for a short period only. Of the others, 
the students were untiring in their devotion to the sick ; often irregular in their 
meals, and having a much smaller allowance of sleep than nature is supposed 
to require. The physicians spent from six to eight hours daily in the house, 
until about the close of the epidemic ; and when the number of patients was 
large, were often engaged in the duties properly belonging to the nurses. Of 
all these attendants, but two had the symptoms of the disease, and in one of 
these they were not all present, and in the other rice-water discharges were 
entirely wanting. Two of the attendants had cholera at the time they entered 
the house, and neither of them had any return of the disease. 

The first patient was received in the hospital on the 29th of June, the last on 
the 29th of September. During this period the entire number received was 
262 ; of these 166 died and 96 recovered. 

We shall present, almost entire, the account given of the post-mortem appear- 
ances detected in the examinations made at the hospital. 

132 Bibliographical Notices. [July 

"The most remarkable and constant appearances were the following: — 

"1st. An unusual dryness of the pleura — particularly where the anterior 
edges of the lungs overlap the pericardium ; so that, on raising them, the two 
pleural surfaces separated from each other with some difficulty, and presented a 
dry and wrinkled appearance, instead of their usual moist and polished aspect. 

"2d. A nearly empty condition of the pericardium; that cavity often contain- 
ing not more than eight or ten drops of fluid. 

"3d. The peritoneum was smeared with a thin layer of slimy opaline secre- 
tion, which was drawn out into minute threads on separating the convolutions 
of the small intestines. When this substance was not in sufficient quantity to be 
visible on the peritoneal surface, it could be collected by drawing a few coils 
of intestine through the fingers, when its slimy, sticky feel was easily recog- 

" 4th. A moderate swelling and opacity of Peyer's patches, and of the solitary 
glands of the lower part of the small intestines — in the large intestine, a simi- 
lar development of the mucous follicles, the mouths of which were often widely 
open, and sometimes marked by a black point. 

"5th. A shrivelled condition of the spleen, with deficiency of blood. 

"6th. A completely contracted and empty state of the urinary bladder, the mu- 
cous surface of which was smeared with a thickish creamy secretion, sometimes 
abundant, sometimes moderate in amount. 

"7th The mucous surface of the vagina was smeared with a somewhat simi- 
lar secretion, but thicker and less opaque than that in the bladder — rather like 
thick starch in consistency and aspect. 

" The whole number of recorded autopsies was 33 ; of these subjects, 12 were 
males and 21 females. The large majority were adults. The youngest was 
eight, the oldest sixty years of age. In fifteen cases there were marks of pre- 
vious disease ; mostly tubercular deposits, peritoneal adhesions, fibrous tumours 
of the uterus, &c. &c. In this are not included such alterations as old pleuritic 
adhesions and simple ovarian cysts; these lesions being everywhere so frequently 
met with. In five cases only was there any previous disease in an active con- 
dition, viz., two of pulmonary phthisis, one of tubercular pleurisy, one of 
cirrhosis of the liver, and one of a fibrous tumour of the uterus, which had in- 
duced redness and softening of part of the uterine substance. 

" Rigor mortis was established in every instance. In one case it was slight, 
and in a few unusually strong — generally, neither deficient nor excessive. 

" The blood was not so much altered, in its gross appearance, as might have 
been expected from previous accounts. It has been represented as quite fluid 
and destitute of coagula. In point of fact, the coagulum was, as a general rule, 
remarkably deficient in quantity, or consistency, or both ; but not, by any means, 
universally. In two cases, the coagulum in the heart was unusually abundant, 
and of firm consistency ; in eight, it was moderate in amount, and of natural 
firmness ; and in twenty, it was small, trifling, or insignificant in quantity, and 
loose, gelatinous, or semi-fluid. In three cases, only, was it entirely wanting. 
Coagula, however, often existed in the heart, when they were not to be found in 
any other part of the body. 

" The consistency of the fluid part of the blood, after death, varied consider- 
ably. In some cases no remarkable alteration was observed ; in some, it was 
recorded as natural ; and, in two or three, it was unusually thin and fluid. In 
fifteen cases, it was more or less thick and tarry, either throughout the system, 
or in particular situations. For, what was sufficiently remarkable, the consist- 
ency of the blood often varied in different vessels in the same subject." 

"No constant relation was found to exist between the consistency of the 
coagula and the length of time the patient had been ill." 

" In five cases, there was a dusky red staining of the endocardium, or some 
of the lining membrane of the vessels, owing to the solution of the blood glo- 
bules, and consequent imbibition of the colouring matter. This took place occa- 
sionally, in certain situations, while the remainder of the vascular membrane 
was free from alteration." " This process had, apparently, some connection 
with the consistency of the blood, though not, perhaps, precisely that which we 
should expect ; the staining sometimes being most strongly marked when the 
blood was thickest." 

1850.] Report on the Asiatic Cholera. 133 

"In fourteen cases, ecchymoses were observed in various situations; mostly 
on the pericardium and external surface of the heart, or internally, immediately 
beneath the endocardium ; occasionally in the cellular tissue of the lungs, on 
the surface of the kidneys, and between the lobules of the pancreas. 

" The brain was, at most, universally natural in colour, vascularity and con- 
sistency. In three cases only was there any appreciable softening of the 
cerebral substance; and in three, some bloody engorgement, viz., in one case, of 
the hemispheres generally; in one, of their superficial parts; and in one, of the 
lining membrane of the ventricles. The effusion of clear or reddish fluid into 
the arachnoid cavity, among the meshes of the pia mater, and into the lateral 
ventricles, was a much more common occurrence. This, however, was moderate 
in amount; the fluid in the ventricles varying from a few drops to two drachms. 
In three cases only was the quantity of fluid in the ventricles considerable : 
in one, these cavities were said to be filled with the fluid ; in another, the 
quantity was estimated at one ounce. 

" The most remarkable circumstance noticed in the head was the presence 
of a quantity of dark, thick, bloody fluid in the arachnoid cavity, over the pos- 
terior part of the convexities of the hemispheres, just sufficient to smear the 
arachnoid surfaces, the arachnoid itself remaining at the same time quite natu- 
ral. This appearance presented itself in fifteen cases. When first observed, 
it was so remarkable and unexpected that it was thought the blood might have 
escaped accidentally from ruptured vessels, through some carelessness in sepa- 
rating the skull from the dura mater ; but it occurred so frequently afterwards, 
and always in the same situation, as to leave no doubt that it was a true morbid 
appearance, and a consequence of the disease. Considering its constant situa- 
tion at the most dependent parts of the brain, and the fact that the arachnoid 
membrane itself always retained its natural transparent and polished aspect, 
this appearance seemed to be, in all probability, rather a post-mortem transu- 
dation, owing to the peculiar condition of the blood, than any effusion which 
had taken place during life." 

Pains were taken to determine this point in one case. The patient lay upon 
her back until the moment of death, when the body was turned immediately 
upon its left side and kept in that position until examined, sixteen hours after- 
wards. In almost every other case the exudation was similar on the two sides 
of the brain. In this it was trifling, light coloured, and thin to the right of the 
longitudinal sinus, but on the left side, copious, dark coloured and thick. In 
one case, besides the above effusion, 

" There was a thin plate of red coagulum on the superior surface of the cere- 
bellum which had taken the form of the cavity into which it was effused. This 
effusion, apparently, must have taken place during life, and at an early period 
of the disease, since the coagulum was considerably firmer than that in any 
other part of the body. 

" Nothing was observed in any instance like the sticky varnish described by 
Tardieu as coating the surfaces of the arachnoid." 

" The spinal cord was examined in two cases. In the first, in which death 
took place in the choleric stage, it was absolutely natural in every respect. In 
the other, in which death took place in the febrile stage, it was decidedly 
softened in the cervical portion, and a little, also, in the dorsal, with some 
bloody oedema of the adjacent cellular tissue. These were the only alterations 

"Though congestion of the heart and lungs may very possibly exist during 
the early stages of the disease, yet it was not generally found to any great extent 
after death. In a majority of cases the lungs were natural in appearance, ex- 
cept for that moderate degree of engorgement of the dependent parts, which 
we are not surprised to see in any subject. In three cases there were marks of 
unnatural congestion. In six, the lungs were deficient in fluids, dryish, much 
collapsed and shrivelled. In one case, there was general emphysema; in two 
ecclrymoses, and in one, where the patient had secondary fever, pneumonia. 

" The right cavities of the heart contained a moderate quantity of blood, in 
fifteen cases, and in thirteen they were full. They were absolutely distended 
in only three ; but these were not the same three cases in which the lungs were 

134 Bibliographical Notices. [July 

congested. In two cases, the quantity of blood in the heart was deficient. The 
left ventricle of the heart was firm and thoroughly contracted in nine cases. It 
was more or less deficient in firmness in thirteen, and in ten it was completely 
flaccid. In one case its condition was only remarked as ' natural/ 

" Contents of the alimentary canal. — These varied greatly in quantity, colour, 
and consistency. They were thick, thin, gruelly, grey, yellow, yellowish, white, 
pink, reddish, or puriform. They were sometimes like soap and water; some- 
times thickish and dull red in colour, as if mixed with red paint ; sometimes they 
presented the appearance of true ' rice water ;' i. e., a thin, whitish, opaline 
fluid, which deposited a quantity of very fine white flocculi, looking, when col- 
lected at the bottom, like a layer of pure pus. Almost always the contents of 
the stomach and the small and large intestines differed from each other in 
colour, consistency, or both." " On several occasions, the ordinary reagents 
showed the presence of albumen in the fluid part of the intestinal contents in 
considerable or moderate quantity. Examined by the microscope, the flocculi 
suspended in the rice-water fluid invariably consisted of columnar epithelium 
floating about in larger or smaller masses, or as detached cells. These epithe- 
lium cells were so abundant and well defined as to leave no doubt that they 
constituted nineteen-twentieths of the mass of the flocculi." 

In reference to the opinion advanced by Dr. Gairdner of Edinburgh, that the 
exfoliation of the epithelium of the intestinal mucous membrane, giving rise to 
the presence of these cells in the dejections and contents of the alimentary 
canal, is entirely a post-mortem occurrence, owing to the maceration of the in- 
testinal mucous membrane by the contained fluid, the report before us presents 
the following remarks : — 

"If maceration is the only cause of the separation of such an enormous 
quantity of epithelium, how shall we explain its occurrence in other situations, 
where no unusual amount of fluid has existed ? The mucous surfaces of the 
vagina, and of the urinary bladder are invariably smeared with a thick, whitish, 
pasty, or creamy secretion, which, on microscopic examination, is seen to con- 
sist entirely of detached epithelium cells, mostly perfect in shape, and generally 
distinctly nucleated. But these passages have not been subjected to maceration. 
The urinary bladder, indeed, is completely empty, and from the first moment of 
the disease, has been deprived of the fluid which it contained in health. Dr. 
Gardner's opinion does not, therefore, ,seem entirely well-founded. The fact that 
epithelium cells are not so distinctly recognizable in the cholera stools passed 
during life, is probably to be explained by the circumstance that, in their pas- 
sage through the intestinal canal, they become, to a certain extent, disinte- 
grated. We have sometimes seen, mixed with the columnar epithelium, small 
roundish bodies like the nuclei of destroyed or unformed epithelium cells. Since 
the violent purging, in cholera, very commonly ceases during the last hours of 
life, we can easily understand why the epithelium cells, thrown off after that 
period, should remain uninjured. The bowels are then comparatively quiet, 
and they are not so much exposed to the causes of injury as those which were 
evacuated in the earlier stages of the disease." 

" The internal surface of the stomach and intestines was almost universally 
pale, or natural in colour. Its usual appearance was that of general paleness, 
with slight or moderate redness in some parts. It was very common to find 
the small intestines generally pale, stained yellow at their upper extremity, and 
moderately reddened toward the lower part of the ileum. In no instance was 
the redness general. The intestinal villi were almost always unusually distinct, 
appearing tumefied, and whitish opaque in colour. The spots of redness were 
not unfrequently produced by scarlet colouration of the villi, while the rest of 
the mucous membrane retained its natural paleness. This condition was very 
readily distinguishable on close examination. 

"The kidneys did not usually present any remarkable alterations in appear- 
ance ; the most common being flaccidity of tissue, without noticeable increase 
or diminution in volume. Beside this, the kidneys were occasionally entirely 
destitute of their ordinary renal odour, and exhaled from their cut surfaces a 
very distinct and peculiar smell, resembling that of molasses. This was noticed 
in only four instances ; but as our attention was not directed to this circum- 
stance until a late period in the epidemic, it may have existed more frequently." 

1850.] Report on the Asiatic Cholera. 135 

It is remarked that decided variations took place during the course of the 
epidemic, in the frequency of certain post-mortem appearances, as well as of 
some of the symptoms during life. At first, the coagula in the heart were not 
unfrequently moderate in quantity and consistency, and sometimes even re- 
markably abundant and firm. Afterward, however, they were almost invari- 
ably deficient and loose, or even entirely wanting. In the early part of the 
epidemic, also, spots of ecchymosis on the heart, externally or internally, were 
an almost constant symptom; at a later period this appearance was rarely met 

The account of the treatment pursued in the cholera hospital at Boston will 
require only a passing notice. The effects of the remedies as there exhibited 
will scarcely advance us a single step in our investigation of the therapeutics 
of cholera. The late period of the disease in which the patients were sent in 
precluded the possibility of any beneficial result being derived from the best 
devised and most energetic treatment. Everything that has been suggested or 
imagined as a remedy in cholera appears to have been tried ; and when these 
were found to fail in arresting the fatal course of the malady, the gentlemen 
having charge of the hospital were willing to try the popular forms of empirical 
practice. " The wet sheet (packing, so called) was tried faithfully; but every 
patient upon whom it was tried died/ 7 Homoeopathy was next invoked to lend 
its aid ; but its professors, who were too cunning to put to so severe a test the 
virtue of drop doses of camphor-water, as an infallible cholera specific, refused 
their aid. Though no doubt they make the most of the invitation extended to 
them, quoting it as a confession, on the part of the regular physicians, of the 
greater certainty of homoeopathic treatment in the arrest of cholera. 

Narcotics, we are told, totally failed of any beneficial effects ; stimulants 
almost always failed ; electricity failed entirely ; calomel produced no evident 
effect ; the same is true of quinia. Ipecaculiana and capsicum in powder, about 
forty grains to a drachm of each, were always exhibited in the early cases, 
with at least temporary relief. The pulse, which was often gone, returned at 
the wrist, and with it, the warmth of surface. It is queried, how much the 
omission of this treatment, if anything, had to do with the greater mortality in 
later cases. " Tannic acid was frequently used in enemeta, in proportions of 
five or six grains to the ounce of fluid, and almost always with temporary relief 
of the purging. By the stomach, in doses of two or three grains, it sometimes 
appeared to check vomiting." The astringents and aromatics had usually but 
little if any effect. Ether, by inhalation, relieved the cramps, but appeared to 
have no effect in arresting the fatal course of the disease. Cathartics were 
never used until the dangerous period was supposed to be passed. Venous in- 
jection was tried but abandoned, its effects being merely temporary. External 
heat and rubefacients were freely employed : but generally, after collapse was 
marked, these remedies had no other effect than to annoy and irritate the pa- 
tients. ''Those patients who could be induced to remain covered with blankets 
fared the best, with or without other artificial heat. Those who were restless 
and threw off the clothing invariably died." Drinks, of whatever nature, were 
useless. Those who drank the least, vomited and purged the least. "Those 
patients to whom drink was steadily refused, neither vomited nor purged freely 
afterwards — often not at all. They more speedily grew warm, and those 
who, for an hour, were kept closely enveloped in blankets, and took no medicines 
and got no drink, suffered the least, and were the most likely to recover." Hot 
baths were painful to the patients, and they generally sank speedily after their 
use. Cold sponge baths were more grateful, and even during collapse they 
seemed for a short time to revive the patients. Bladders of ice to the head 
and cold effusion were resorted to, advantageously, in cases of violent delirium. 
Bleeding by the lancet and by cupping was several times resorted to. Before 
the cramps ceased great relief was experienced from the lancet ; later, like 
other remedies, it was of little avail. "Of bleeding, in an early stage of the 
disease, we are inclined," the reporter remarks, " to speak quite favourably, 
though not with so much enthusiasm as many East Indian surgeons do. The 
extraction of blood from the nape of the neck by cups, was, in a few cases, 
useful." Creasote sometimes seemed to relieve the vomiting, but not so invari- 

136 Bibliographical Notices. [July 

ably or effectually as the wood naphtha, which failed in no case in which it was 
used. It was given in various doses, clear, from twenty miniums to a drachm. 

"Much benefit was thought to be derived from the exhibition of saline medi- 
cines. Stevens' mixture of the chlorate of potash, in solution, with the hydro- 
chlorate and bicarbonate of soda, was the form in which salines were usually 
given. We used larger doses of the chlorate, generally, than Stevens recom- 
mends, but are not able to say that this was an advantage." 

In all the fatal cases, post-mortem contractions were either seen or could be 
excited. They generally commenced about fifteen minutes after death. In one 
case the muscular action was so great, thirty minutes after death, that the 
nurses supposed the subject to be still alive. The external muscles in this case 
were in constant action, the motions progressing, like tides, from one to the 
other of their extremities. The contractions were strongest in the extensors of 
the thighs. 

Upon the whole, the report before us is a highly interesting one. Although it 
throws but little light upon the pathology and treatment of cholera, it records 
facts of great importance to the future historian of the disease. D. F. C. 

Art. XXII. — The Annual Report of the Board of Health of the City of New 
Orleans, for 1849. 8vo. pp. 16. New Orleans, 1850. 

This is a very interesting report. We confess, however, that we cannot com- 
mend the style in which it is written, but are disposed to overlook its deficiencies 
in this respect, in consequence of the valuable facts and suggestions it presents 
in reference to the sanitary condition of the great emporium of the south. 

The report is made in obedience to a provision contained in the Act passed 
in 1848, for the establishment of a Board of Health, in and for the parish of New 
Orleans, requiring a report as to the health of the city for the preceding year, 
and suggestions as to the means for improving the same, to be made annually 
to the several councils. 

The importance of an accurate registration of deaths in every community 
is pointed out, in the commencement of the report, in language scarcely too 
strong: — 

" If a city or country is ignorant of the diseases fatal to its population ; if it 
does not know the age at death, sex, colour, length of residence, occupation, 
and in what part of the city death took place, it must be ignorant of one of its 
most important duties ; that which is dearest to every human being, its sanitary 
condition; the influence of the place on the lives of the inhabitants; the actual 
climate in which they live — the value of life there, or expectation of living ; on 
what portion of the population it bears with greatest or least severity, or what 
part of the city requires ameliorations ; in fact, whether that community is 
advancing or retrograding in these important particulars : and all laws intended 
to benefit the sanitary condition without a previous knowledge of what that 
sanitary condition is, are deficient in the basis of all wise legislation, and trifle 
with common sense." 

Though badly constructed, the foregoing sentence expresses truths which it is 
the duty of physicians throughout our Union to press upon the attention of the 
legislatures of the several states, in the hopes of inducing them to provide by 
law for the accurate registration, not only of the deaths which take place in 
each section and locality within their jurisdictions, but also of the births and 
marriages, without a knowledge of which the actual sanitary condition of any 
given place can scarcely be determined with certainty. To use the language 
of the report before us : — 

" All other modes of estimating the prosperity of a community are deceptive ; 
it is in vain to look at the increase of the exports and the imports ; its growth 
in area ; its splendid architectural ornaments, even its increase in population, 
all are illusory ; the true touch stone is its sanitary condition ; — the deaths to 
population ; the average age at death ; the real value or expectation of life," 
and, we would add the ratio of births to marriages, and of deaths to births. 

1850.] Report of the Board of Health of the City of New Orleans. 137 

" What is wealth without health, or continuance of life to enjoy it ? Immigra- 
tion may fill up the gaps caused by death ; a floating population may, in a few 
months, accomplish your principal commercial business, and your fine port may 
be but a depot for the exchange or barter of commodities, for people living in 
different parts of the world, utterly indifferent to your interests/' 

After some remarks upon the general causes peculiar to New Orleans, which 
affect prejudicially the health and life of its inhabitants, the report proceeds 
to notice the leading diseases which prevailed in that city during the year 
1849. From this portion of the document we derive the following remarks : — 

" With reference to the great epidemic principle giving rise to cholera, whose 
devastations have been so severe throughout our eountry, it is some consolation 
to know (poor as that is) that it derived no influence from our position. Not- 
withstanding its originating in a latitude, climate, and on a great stream sur- 
rounded with swamps, somewhat similar to our own, there are moral aspects, 
grades of civilization, and wide extension of comforts, that produce an immense 
bearing on the disease, widely distinguishing our happy country from the down- 
trodden millions of oppressed India ; and the difference between that country 
and this is almost as great as between the present and fifteenth century, when 
plagues so often ravaged the earth, with a severity far exceeding that of latter 
times. It is farther observable, that there is scarcely a large city in the Union 
where it has prevailed that it has not been more severe than here, notwithstand- 
ing the peculiar character of our floating population." 

" Medical science has done much for its relief; when left to itself cholera is 
almost uniformly fatal, but, with our present knowledge of its preventives, the 
scourge itself, to the prudent and temperate, excepting in embarrassed con- 
stitutions (?), is scarcely ever to be dreaded. It is some consolation, then, in 
relation to this disease, which cometh and goeth under laws and conditions so 
little understood, that each individual carries his safeguard under his own 
control in the correctness of his personal habits. The liability being individual, 
the municipal power can only aid by cleanliness and ventilation. 

" Accompanying the belief that, as it originated in a climate in many respects 
similar to our own, there was, probably, one feature common to both in which 
they participated, that being the prevalence of great moisture, from similarity 
of topographical situation ; and that, consequently, it may be expected to remain 
permanently among us. By reference to the chart, it is gratifying to perceive 
that this is a great mistake, and that dryness, instead of moisture, has been so 
remarkable as to appear to act in the line of causation. We had, during the 
worst of its devastation, a prevalence of dry fogs, once noticed by Humboldt, in 
passing the Andes, and centuries ago, by others, as accompanying (and probably 
causing) epidemic influenza (the uniform precursor of cholera). These lines 
of aridity (force of evaporation and low hygrometer) and cholera are marked 
on the chart, and it really seemed that the disease declined as the moisture in- 
creased and the rain fell. 

" The amount of mortality produced by it during the year has been three 
thousand one hundred and seventy-six." 

" The mortality from the class of fevers, the great outlet of human life in the 
south, is small, constituting about 14.58 per cent, of the entire mortality; of 
which, more than half, or 55.30 per cent., is from yellow fever." " Whether we 
shall ever get rid of the latter is a problem impossible to solve with the lights 
at present before the profession; we don't know its cause [causa sine qua non). 
That all fevers, this inclusive, will be more rare as the laws of general and 
personal hygiene are applied to communities and individuals, we know from 
the results of actual experience, and, therefore, there is no doubt, as these im- 
provements progress, yellow fever will, as already remarked by professional 
men, lose its individuality, and become blended with ordinary fevers." 

" The next class of diseases to which your attention is invited is the pulmo- 
nary ; and here we have especially to lament that deficiency in the certificates, 
first noticed, in relation to ' residence ;' many doubtless visiting this mild climate 
on account of its kindness to pulmonary invalids, and here falling victims to 
the disease already beyond the reach of art or climate, and adding to our 
mortality in that respect. The whole class amount to 876, of these consumption 

138 Bibliographical Notices. [July 

embraces 592 ; leaving only 284 for all other pulmonary diseases ! By the fol- 
lowing table it will be seen that, notwithstanding the addition made to our 
mortality by immigrants and visitors with these diseases, yet we are more 
favoured in these respects than any large city in this hemisphere. 

Deaths from phthisis 

Deaths from all pulmonary- 

to total mortality. 

diseases to total mortality. 


14.84 i 

per ct. 

28.57 per ct. 

New York, 

























Mexico (city,) 










New Orleans, 





" The above extraordinary results have been made from official sources. The 
Reporter took the years as he had access to them, mostly the year 1845, and, 
from most of them he deduced the causes of death, not diseases, before he made 
the ratios." 

In regard to Philadelphia, the ratio given above is not perfectly accurate. 
From the bills of mortality for thirteen consecutive years, omitting the still 
born, and deaths from old age and causalties, we find that the deaths from 
phthisis amount to 14.4 per cent, of the entire mortality ; while the deaths from 
all diseases of the respiratory organs including those of the larynx, croup and 
asthma, constitute but 26.79 per cent, of the total mortality. 

The entire mortality of the city of New Orleans for 1849, was 9862; of these 
deaths about 29 per cent, occurred in the various hospitals. Deducting 3176 
deaths, from cholera, and 372 from causes other than disease, leaves a net mor- 
tality of 6314; being at the rate of 1 to every 16.67 of the inhabitants or 5.99. 
The stationary population being estimated at 105,347 ; based upon an increase 
of 5.32 per cent, annually over the population of 1847, when the last census was 

" This," the report remarks, " is a very large mortality: of course a very con- 
siderable portion of it being derived from that mass of floating population not 
enumerated in the census, and which should have been stated in the mortuary 
certificates, had they been made according to the request of the board." 

After presenting a number of judicious suggestions for the improvement of the 
sanitary condition of New Orleans, the report enters into an examination of the 
probable chances of life in that city, compared with these chances in other 
localities. With an extract or two from this portion of the document, we shall 
close the present notice. 

" The average life in no country reaches three score years and ten, announced 
in Scripture as the period for the duration of the life of man. The average age 
at death in the northern cities — doubtless owing in a great measure to the large 
mortality in infantile life — is from 19 years 9 months to 20 years 3 months, 
and in some of the cemeteries where destitute foreigners from the crowded parts 
of the city of Boston are buried, it is reduced to 13.49. In the south, where it 
is so much more favourable to infantile life, the average age is much greater. 
In Charleston the average age at death is near 36 years. In Vera Cruz 24.6, 
and in the city of Mexico 27.7 ; while in the city of New Orleans, the average 
age at death for the last year was 26.69, and in a series of the years, the aggre- 
gate of all the cemeteries was 22 years 6 months 3 days." 

" Of all countries on record, the rural parts of England and Massachusetts 
are probably most favoured with respect to infantile life ; and yet in Massa- 
chusetts 40 per cent., and in England 47 per cent., die while they are going 
through the process of development, and before they enter upon self-sustaining 
life, in their 16th year. In New Orleans we have not the data to institute an 
exact comparison at these ages, but very near it ; and we find that here only 
36.98 per cent, die under 20. In this city, data of all kinds are defective ; we 
have, nevertheless, been able to construct a chart, to show the real value of life 

1850.] Benjamin on some of the Diseases of the Nails. 139 

here at successive ages, and at different periods of the year. It is too lengthy 
for this report. We may, however, state that it shows the extremely mild charac- 
ter of the climate at all periods of life under 20, and above 50, and during all 
months of the year, and that the chief fatality occurs from 20 to 40 (the ages 
of the immigrating population), and the period, the latter part of summer. Not- 
withstanding all this, the following statement shows that we have a larger pro- 
portionate population at the productive age, that is from 20 to 50, than the most 
favoured parts of the world : viz., in 

every 10,000 in the United States, there are 3,708, 
" 10,000 " Louisiana, " 3,753, 

" 10,000 " England and Wales, " 4,028, While there are in 
" 10,000 " New Orleans, " 4,924. 

"From all the information we can procure, it is satisfactorily demonstrated, 
that in countries where from climate, position, and refinement, a very small 
part of the population reach the age of their natural destiny, they approach it 
nearer, in proportion as they obey the laws which are adapted to the guidance 
of life : here, notwithstanding our deficiencies in many respects, sufficient is 
ascertained to hope for as near an approximation to the primeval age as any- 
where, and reference to the table showing the number of the dead above 80 and 
100 — 11.58 per cent, of the first and 2.26 of the second — buried at the Catholic 
cemetery ; the chief cemetery of the ancient Creole population of the city — will 
satisfactorily prove the fact." 

An interesting chart and several valuable tables accompany this report. 
Could all our boards of health be induced to publish annually reports similar 
to the one before us, it would be the means of accumulating important materials 
for determining the relative sanitary condition of our different cities, and for 
aiding us in our investigation of their respective endemic diseases. 

D. F. C. 

Art. XXIII. — Nonnula de Morbis Unguium. Auctor Ludovicus Benjamin, 

On some of the Diseases of the Nails. By Lewis Benjamin, of Hamburgh. 

Berlin, 1849: 12mo. pp. '32. 

In looking over a number of inaugural theses, published by the medical 
graduates of the Berlin University, of the session of 1848, we were struck with 
the title of the one before us. We felt curious to know what are the diseases 
of the nails, with which, we confess, we were previously entirely unacquainted. 
The morbid conditions of these tegumentary appendices treated of by Br. Ben- 
jamin are hypertrophy and atrophy ; panaritium or whitlow ; incarnation of 
the nail, and onychia maligna. 

The first two may, it is true, be considered with propriety as strictly diseased 
conditions of the nails, but certainly neither of the others, excepting so far as 
they occur in the neighbourhood of these parts, and very frequently cause 
their destruction. 

We have met with numerous instances of what the author has denominated 
hypertrophy and atrophy of the nails. One or more of the nails, particularly 
those of the toes, though occasionally of the hands, will become greatly thick- 
ened, and extended far beyond the extremity of the phalange to which they 
appertain, often bending over the end of the finger or toe, and terminating in 
a sharp-, claw-like point. The thickening is generally to the greatest extent in 
the centre of the nail, causing it to assume a pyramidal shape ; in some in- 
stances, we have known the thickening to occur in bands arranged either longi- 
tudinally or transversly. The affected nail becomes opaque, has a rough, often 
scaly, surface, and a dark, dirty yellow, or brown colour. On the other hand, 
we have seen one or more of the nails, greatly and permanently reduced in 
length and breadth ; often, however, at the same time thickened, rough, and 
opaque. The actual cause of these changes from the normal condition of the 

140 Bibliographical Notices. [July 

nails, it is difficult to determine. In some of the cases we have met with, they 
were evidently caused by undue pressure from badly constructed boots and 
shoes, or from the tools employed by the individuals in their daily occupations; 
in other cases, they were the result of lacerated wounds or bruises in which 
the nails were implicated ; in a few, they were consequent upon paronychia, 
and, in other cases, again, they appeared to occur spontaneously, or, at least, 
without any assignable cause. These changes in the condition of the nails are 
seldom productive of much inconvenience. When they occur in the nails of 
the feet they scarcely attract the attention of the individual ; those of the 
finger nails are now and then brought to the attention of the physician, with 
the hope that he may be able to remove the deformity caused by them. 

We know of no remedy for these morbid conditions of the nails. Dr. Benja- 
min, who describes the state of hypertrophy as occurring invariably in the 
nails of the feet, especially that of the great toe, recommends for its removal 
an easy, light shoe of soft leather or cloth, diminished exercise or entire rest 
of the foot, or, after paring away the nail, to encircle it with strips of adhesive 
plaster so as to prevent any pressure being applied to it. Believing that the 
deviation from the normal state of the nails is dependent upon some morbid 
change in the matrix, by which their symmetrical formation is prevented, we 
have little faith in the efficacy of any of the measures that have been proposed 
for its removal. 

Dr. Benjamin presents a very good description of that form of whitlow or 
paronychia, which occurs in the soft part at the edge or beneath the nails. He 
describes the ordinary treatment : cold applications, leeches, &c, in the stage 
of inflammation ; and when suppuration has taken place, free incisions. The 
best remedy in the early stage of the disease we have found to be a blister. 
The inflammation has often been cut short by clipping the end of the finger in 
water, sufficiently hot to produce immediate vesication. 

The nature of what is termed incarnation of the nail has been very gene- 
rally misunderstood, and from the erroneous supposition that the lateral edge 
of the nail actually grows into the flesh, the severe and unjustifiable operations, 
described and recommended in the work before us, have actually been practiced. 
The whole of the mischief in the cases alluded to is caused by the soft parts 
at the side of the nail being forced by external pressure — a tight or misshapen 
shoe, for instance, for the accident is generally in the great toe — against and 
over its edge. In many instances, ulceration occurs in consequence of this 
pressure, attended with profuse fungous granulations, and a bloody, sanious dis- 
charge. The sufferings of the patient are now such as often entirely to pre- 
clude him from wearing a shoe or putting the affected foot to the ground. The 
edge of the nail appears to be actually imbedded deep in the flesh, and, at first 
view, it would really seem as though a cure could only be effected by removing 
the imbedded portion. But no operation beyond that of the entire extirpation 
of the nail will afford permanent relief; happily they are all unnecessary, as 
by rest, the treatment of the ulceration by slightly stimulating applications, 
and, as soon as the tumefaction and excessive tenderness of the parts have been 
sufficiently reduced, the interposition beneath the edge of the nail of a portion 
of diachylon plaster or of lint, and a loose, well-shaped boot or shoe, a perfect 
cure may, in a short period, be effected in every instance. 

The onychia maligna, or, as Dr. Benjamin describes it, inflammation and ul- 
ceration of the cutis beneath the nail, is a frequent and painful affection. After 
great and long-continued suffering, the nail becomes separated from the finger 
at every part except its matrix. An unhealthy ulcer forms about the root of 
the nail, shooting forth profuse fungous granulations, which bleed upon the 
slightest touch ; the surrounding soft parts become swollen, of a dusky red or 
purplish blue, and exquisitely tender. If the disease be not arrested, the toe 
or finger becomes enlarged, bulbous, and ulcerated throughout, and may con- 
tinue so for a long period ; not the slightest disposition to cicatrization being 
observable so long as any portion of the nail remains attached. 

If the case is seen sufficiently early, the ordinary means for the reduction of 
inflammation should be resorted to : leeches, emollient fomentations, saline pur- 
gatives, an elevated position of the part affected, and surrounding the end of the 

1850.] Fenner, Southern Medical Reports. 141 

inflamed finger with a blister. After ulceration has taken place, the best appli- 
cation we have found to be an ointment composed of four parts of basilicon 
and one of red precipitate ; an ointment composed of one drachm of the pre- 
cipitate ointment, fifteen grains of sulphate of zinc, and one ounce of lard or 
simple cerate, will often be found of advantage. A plan, originally proposed 
by Dr. Perkins, of Philadelphia, and recommended by Dr. Physick, was to 
sprinkle the diseased surfaces with a powder composed of equal parts of sul- 
phate of zinc and corrosive sublimate, and then to cover them with a pledget of 
lint soaked in laudanum. 

To promote the cicatrization of the ulcer, the patient should be placed in a 
pure, free atmosphere, take daily out-door exercise, and partake of a light, whole- 
some diet. The bowels should be kept free by mild laxatives, and when there 
is evident derangement of the alimentary canal, occasional doses of blue mass, 
and light bitters or tonics, will be advisable. 

When only the upper portion of the nail is detached, the ulceration not im- 
plicating the matrix, after removing carefully the loose portion with the knife 
or scissors, under the treatment just pointed out, the ulcer, in general, soon 
assumes a healthy aspect and cicatrizes perfectly; but when, as is generally the 
case, the disease commences at the lower part of the nail, a portion of its root 
being detached, unless the whole of the matrix is removed, the ulceration may 
be kept up, and the patient's sufferings prolonged for many months. 

The foregoing remarks upon the diseases treated of in the dissertation of 
Dr. Benjamin, have been suggested by a perusal of its several sections. While 
we have been pleased, in general, with the accuracy of the author's descrip- 
tions, and much that he advances in regard to the etiology of the so-called 
diseases of the nails, we differ from him very far as to their proper treatment. 
That laid down by him for the cure of incarnation of the nail is founded 
upon a misconception of the nature of the accident it is intended to remedy 
— it inflicts unnecessary suffering, and is inferior even in eflicacy to the plan 
we have referred to above. D. F. C. 

Art. XXIV. — Southern Medical Reports ; consisting of General and Special Re- 
ports on the Medical Topography, Meteorology, and Prevalent Diseases in the 
following States : Louisiana, Alabama, Mississippi, North Carolina, South 
Carolina, Georgia, Florida, Arkansas, Tennessee, Texas. To be published 
Annually. Edited by E. D. Fenner, M.D., etc. etc., of New Orleans. New 
Orleans and New York : Vol. I. 1849 : 8vo. pp. 472. 

It is gratifying to observe the attention that is beginning to be bestowed by 
our physicians to the investigation of the medical topography, in connection with 
the prevailing diseases, of the. different sections of the United States. The in- 
vestigation is a highly important one, inasmuch as it is from the materials it is 
calculated to afford that we are to derive our means for the elucidation of some 
of the most interesting points in relation to the etiology of many diseases, es- 
pecially of those endemic to particular sections or districts of country, or to 
particular localities. 

The work of Dr. Drake, on the medical topography and diseases of the inte- 
rior valley of North America, and the cotemporaneous one of Dr. Fenner, on 
the same subjects in reference to the several southern States, furnish most 
valuable contributions towards a full and accurate exposition of the etiology of 
the prevalent diseases of a considerable portion of our wide extended country. 
While we bespeak for the works of these gentlemen the liberal patronage of 
the profession, we cherish the hope that their labours may be the means of 
stimulating physicians in the Northern and Middle States to an investigation 
of the medical topography and prevalent diseases of their own neighbourhoods. 
Were physicians, in the different sections of each State, to devote a portion of 
their time to such investigation, a series of observations would soon be accu- 
mulated, from which results of incalculable value might be deduced. 

The work of Dr. Fenner — a volume of which it is his intention to publish 
No. XXXIX.— July, 1850. 10 

142 Bibliographical Notices. [July 

annually — consists of reports on the medical topography, meteorology, and 
prevalent diseases of the several Southern States, from physicians residing in 
different portions of those States. The plan is an admirable one, and cannot 
fail to render the work a rich collection of materials, in relation to the subjects 
indicated, from which the etiologist may derive the clearest light to assist him 
in the investigation of the causation of endemic diseases. 

Derived from different sources, and embodying observations more or less 
numerous and extended, and recorded with more or less minuteness and 
precision — the authors occasionally throwing aside the character of simple 
chroniclers of the actual facts and phenomena they have observed, to devote 
themselves to the more seductive task of weaving hypotheses — the reports con- 
tained in the volume before us differ, as would very naturally be expected, 
somewhat in value : they are all, however, interesting — several of them pecu- 
liarly so. 

An analysis of the contents of this first volume of Southern Medical Reports 
would occupy considerable space, and we are persuaded that it would be unne- 
cessary to attempt such analysis, as all who are interested in the subjects em- 
braced in these reports, as well as those who are really desirous of promoting 
a national medical literature, will not fail to provide themselves with a copy of 
the work. 

In the report of Dr. Fenner, on " the fevers of New Orleans," will be found 
some important suggestions in relation to the nature and treatment of the 
yellow fever of that city. We have long entertained the opinion that the ma- 
lignant form of fever endemic to the city of New Orleans, and usually denomi- 
nated yellow fever, was nothing more than an aggravated form of bilious fever. 
This opinion is confirmed by the statements of Dr. Fenner : — 

" In New Orleans/' he remarks, "we have met with all the forms of endemic 
fever which were familiar to us in the country (West Tennessee, Mississippi, 
and Madison Parish, La.), with the addition of yellow fever and ship fever, or 
genuine typhus. We have found those common to the city and country to 
prevail at the same season, and in a similar manner, excepting that we met 
with a more rapid and malignant congestive fever in the country than in the 
city, and the bilious remittents of the country retain their character throughout 
more than they do in the city. Here, in the summer and autumn, they have a 
decided tendency to crisis by hemorrhage. This makes yellow fever — it forms 
the true characteristic difference between the high grades of summer and 
autumnal fever in the city and country, and must depend on locality and attend- 
ant circumstances. We have intermittent, remittent, and continued fevers, 
alternating in type and running into each other, just as they do in the country. 
Intermittent fever prevails here throughout the year- as it does in the country. 
During the healthiest years, it predominates over all other types ; but during 
the sicklier years, in the country, it runs into remittent, bilious, and congestive, 
whilst in the city it runs into yellow fever." 

The true yellow fever we believe to be a disease strictly specific in its charac- 
ter — and very distinct from intermittent or bilious remittent fever — well marked 
in its diagnostic characteristics, and, in a strict pathological sense, never con- 
nected with nor terminating in remittent fever. 

It is due to Dr. Fenner to say that, in the course of his report, he somewhat 
modifies his opinion in regard to the character of yellow. After stating, ex- 
plicitly, that intermittents, remittents, and yellow fever are "all the same dis- 
ease, differing only in grade and stage, 7 ' he subsequently declares that he does 
not assert, with Rush and others, 

" That yellow fever is nothing but a high grade of bilious fever; for we admit 
that the latter is sometimes the most malignant of the two, without displaying 
the characteristic features of the former. Our position is, that yellow fever is 
only one of the forms of endemic fever (malarious, if you will), which derives its 
characteristic features from the locality and attendant circumstances wliere it pre- 

Dr. Fenner' s plan of treating yellow fever, we give in his own words : — 

" When called to a case within twenty-four or thirty-six hours of the attack, 
we seldom failed to cut short the fever by large doses of the sulphate of quinine 

1850.] Fenner, Southern Medical Reports. 143 

in combination with opium or morphia, frequently followed by a little blue 
mass or calomel. Our usual mode of proceeding in this stage is, to order, at 
first, a hot mustard foot-bath, and a purgative enema — then to give to an adult 
twenty-five or thirty grains of quinine with twenty-five or thirty drops of lauda- 
num, or one or two grains of opium, or the fourth of a grain of sulphate mor- 
pbiae, at one dose. This would generally reduce the vascular and nervous 
excitement completely in the course of a few hours, throw the patient into a 
profuse perspiration, relieve all pain, and produce sleep. The bowels were kept 
open by some gentle means, and more or less quinine was repeated as occasion 
required. We recollect but one fever patient that required cupping, and we 
did not have a single one bled from the arm. 

"In the early stage of yellow fever, the derangement of the system is entirely 
functional, and consists, chiefly, in lesion of innervation. In the advanced 
stages, it is altogether a different affair. Organic lesions have then taken place, 
and the blood is altered. As soon as the attack is fully developed, the indica- 
tions are, to reduce nervous and vascular excitement, relieve pain, and keep 
the principal emunctories (skin, liver, kidneys, &c.) in steady and free action, 
thus arresting diseased action in the incipient stage. Experience has proved 
that all this can be done by the remedies just mentioned, if resorted to early 
enough. In the advanced stages, you have a different state of things — you have 
to contend with engorgement of the gastro-intestinal mucous membrane, and of 
the liver, spleen, kidneys, and brain ; a sluggish circulation of altered blood, 
and an arrest of all the most important secretions. The nervous centres, which 
first suffered and complained, now become calm and composed, the intellect 
generally retains its natural clearness, and the patient is often lulled into an 
illusive sense of safety, whilst the experienced physician knows that irreparable 
injury has been already done. In these latter stages, the physician should ab- 
stain from attempting to do too much. The main reliance must be upon the 
energies of the constitution, which are to be aided and fostered with the utmost 
circumspection. The indications are, to husband, carefully, the remaining 
strength, to keep the circulation and excitement as well equalized as possible, 
to restore the suspended secretions, and to keep up the process of nutrition. 
To fulfil these, we endeavour to enforce the most perfect quietude, and resort to 
blisters, warm sponging, fomentations, carminative antacid mixtures, gentle 
stimulants, and mild nourishment." 

The report, by the same author, on " the epidemic colic which prevailed in 
the city of New Orleans, during the summer of 1849," is full of interest. 

The majority of the reports, in the volume before us, are in reference to epi- 
demic cholera, as it appeared at different localities in the southern States. We 
would particularly refer to that of Dr. Booth, " on the cholera of Lafourche, 
interior," as one replete with sensible observations in reference to the disease. 
We lay out of question the speculative opinions of the author ; his remarks on 
the management of the disease are, generally speaking, sound, and deserving 
of close attention on the part of the profession. 

The annual report of the New Orleans Board of Health, for 1849, which is 
published here entire, we have noticed in another part of the present number 
of the Journal. 

We recommend the work of Dr. Fenner to the notice of the physicians of the 
United States — as well those located in the Northern, Eastern, and Western, as 
in the southern sections of the Union. As a collection of valuable contribu- 
tions on subjects of immense importance to all — whether these contributions 
were originally prepared for the work itself, or appeared originally in one or 
other of the medical journals of the day — it is deserving of an attentive 
perusal upon the part of all who desire information in relation to the several 
forms and locations of the leading diseases endemic to our country, while from 
its pages facts and observations will be derived calculated to throw light upon 
the etiology, character, and treatment of those affections which prevail in 
other portions of the Union than that comprised within the limits of the 
southern States. D. F. C. 

144 Bibliographical Notices. [July 

Art. XXV — Ship Fever, so called; its History, Nature, and Best Treatment. 
The FisJce Fund Prize Dissertation, for 1849. By Henry Grafton Clark, 
M.D., Member of the Boston Society for Medical Improvement. " Per Ardua." 
Printed by order of the Rhode Island Medical Society. 8vo. pn. 48. Boston, 

Dr. Clark has not entered into a very elaborate investigation of the patho- 
logy of ship fever. His dissertation, nevertheless, presents a very sensible and 
well written exposition of the peculiar character and treatment of the fever with 
which, under that name, we have unfortunately become of late years familiar, in 
consequence of its extensive prevalence among the immigrant passengers from 
Europe, who have crowded our principal commercial cities and their immedi- 
ate vicinities. \ 

In one of the hospitals opened for the especial reception of immigrants labour- 
ing under ship fever, the observations which form the basis of the present dis- 
sertation were made. There two thousand cases of the disease fell under the 
personal notice of the author ; consequently his opportunities for studying its 
symptomatology and usual course, and the means best adapted to arrest its 
fatal termination, have been sufficiently ample. 

Dr. Clark believes that the disease which forms the subject of his dis- 
sertation is identical with that described by Howard, Pringle, Houxham, 
McBride, Darwin, and others, under the various titles of jail, hospital, or camp 
fever; putrid malignant fever; putrid continual fever; petechial fever, macu- 
lated typhus and English or Irish typhus. And farther., that it is very clearly 
different from any fever which has hitherto been known in this country. 
There is every reason to fear that with the present rush of immigrants to our 
shores from England and Ireland, although it has until recently been only an 
exotic, it will soon become domesticated among us, and hereafter loiter around 
or fix itself permanently in the purlieus of all our great maritime cities, if it 
do not follow the great avenues of travel into the interior, especially into the 
manufacturing towns. 

Dr. Clark believes the typhus fever which has occasionally prevailed in this 
country, particularly in the New England States, often as an extensive epidemic, 
is an entirely distinct disease from that known as ship fever, the first being 
typhoid fever, the latter the true typhus of Great Britain. 

No extended examination is, however, entered into to prove the distinct nature 
of these two diseases. The author contents himself with a simple statement of 
the leading points in which they differ from each other. 

According to Dr. Clark, typhoid and typhus fever differ in their access, their 
progress, and their termination. 

" Typhoid fever is slow and insidious in its attack ; often of unknown origin ; 
only contagious in a modified degree, and under certain circumstances; not in- 
fectious ; there is generally diarrhoea, and often hemorrhage from the bowels ; 
epistaxis ; its diagnostic tache, consisting of a sparsely scattered pink eruption, 
is chiefly confined to the abdomen and lower part of the chest, and disappears 
on pressure. The duration of the disease is from two to twelve weeks, the 
average being about three weeks. An ulceration or inflammation of Peyer's 
glands is always found on post-mortem examination. It attacks subjects in all 
conditions of life, and is not prevented by any attention to cleanliness and venti- 

" Typhus fever, on the other hand, is of sudden and violent access, often seiz- 
ing the patient instantly upon his exposure to the exciting cause ; it originates 
from well-known causes ; is confined to those exposed to contagion from the 
sick, or from exposure in a bad atmosphere, and filthy and badly situated tene- 
ments, crowded with animal exhalations ; it is infectious, and in the majority 
of cases is unaccompanied (in its acute form) with diarrhoea. The eruption is 
very abundant, often being sprinkled over the trunk, head, and limbs. It is of 
a dirty red colour, does not disappear on pressure, and frequently, as the disease 
progresses, becomes of a dark brown, which sometimes remains even after death. • 
The eyes are dull and suffused. The duration of the fever is about fourteen 

1850.] Clark on Ship Fever. 145 

days. There is no inflammation of Peyer's or Brunner's glands, although at 
the same time the whole neighbouring intestine is often seriously affected. 

"Finally, the secondary affections of the absorbent system, and the peculiar 
ulceration of the large intestines (the cause of a most fatal hemorrhagic diar- 
rhoea), are worthy of especial notice as common sequelae to ship fever. They 
do not occur in typhoid fever. In fact, the distinctions must be so obvious 
that the diagnosis of a well marked case ought never to be doubtful." 

Although, in the foregoing sketch of the differential diagnosis of typhoid and 
typhus fever, all the features which characterize each of these diseases are not 
noticed, still it is sufficiently full and accurate to enable any one to distinguish 
between them. After all, however, the question, Are these two forms of 
typhus fever specifically different, or are they merely different grades of one 
and the same disease ? remains unanswered. If it can be shown that in the 
one there is invariably present an inflammation of the solitary glands and gland- 
ular patches of the intestines, which is invariably absent in the other, this, 
with the difference in the symptomatology and general course of the two dis- 
eases, would certainly be sufficient to establish a specific difference between 
them. But this is still the point in dispute : many assert that the inflamma- 
tion of the glandiform bodies of the intestines occurs, also, frequently in cases of 
unquestionable typhus ; and we have certainly seen cases occurring on board of 
immigrant passenger ships where the typhus fever prevailed, or in those who 
have recently landed from such vessels, marked by the very symptoms described 
as those diagnostic of typhoid fever, and presenting after death the same lesions 
of the intestines. 

Ship fever, according to Dr. Clark, is communicable by contagion. In the 
hospital under his charge, on Deer Island, Boston Harbour, all the nurses, who 
were usually themselves immigrants, were successively attacked, and several 
of them died. The physician had fallen a victim to the disease, and when Dr. 
C. first undertook the superintendence of the establishment, the only remaining 
assistant physician was sick with the fever. He considers it also to be infec- 
tious, lie has known a considerable number of instances in which the disease 
was unquestionably propagated by chests of clothing, &c, without any personal 
contact with the sick. 

" In all probability," he remarks, " one attack of ship fever, as in the case of 
the other exanthems, generally precludes another ; and although there are well- 
known instances in which the disease has occurred a second or even a third 
time, yet, as a general rule, the protection is complete ; and if the secondary cases 
do sometimes occur, they are in a milder form and much less to be dreaded. 
Indeed, from a personal familiarity with nearly two thousand cases, we are sure 
that this is the rule, and that second cases are the exceptions to it ; for we are 
quite certain that we have known more instances of varioloid after small-pox, or 
second attacks of measles and scarlatina in a greater number of cases than of 
ship fever. It must be understood that the secondary diseases which occur 
after the fever, and are only appendages to it, are not referred to, for these are 
frequent and often fatal. The point is, that second attacks of the primary fever 
after an entire recovery are exceedingly rare, even with the greatest exposure." 

The disease is seldom propagated from a single patient in a well-ventilated 
house ; even in a large hospital, with strict attention to insure the cleanliness of 
the persons, clothing, and bedding of the patients, and a proper ventilation of 
the apartments, the disease will not spread. 

"In this particular it differs essentially from typhoid fever, which, although 
its contagious properties may be considered to be much below those of typhus, 
yet it will often be found that typhoid fever will persist in spite of the most 
energetic measures of cleanliness and ventilation. The poison of typhoid fever 
seems to be of a more subtile character, and decidedly less amenable to any 
hygienic rules of this sort." 

"Ship fever," Dr. Clark remarks, "like the other exanthems, is ordinarily a 
self-limited disease, its most usual duration being fourteen or fifteen days, the 
great majority of cases of the primary fever terminating within that period. 
Nevertheless, so far as our experience goes, at least two-thirds of all the deaths 
occur at a much later period. They are caused by the secondary diseases, 

146 Bibliographical Notices. [July 

which follow, after a certain period of partial recovery, so that they may be 
considered as relapses." 

This corresponds with our own experience. In the cases of ship fever which 
have fallen under our notice, in the greater number of those which terminated 
fatally, death was unquestionably the result of the secondary affections — 
particularly the diarrhoea, which is so liable to occur after a partial recovery from 
the primary disease. We cannot, however, agree with Dr. C. in regard to the 
absolute contagiousness of either the typhus or typhoid fever — that the first is 
communicable in small, filthy, ill-ventilated and crowded apartments, as well as 
by the filthy clothing of the sick, when shut up from the air, we admit; but, 
as the author has himself shown, its communicability is effectually prevented 
by cleanliness and ventilation, which would not be the case if the disease was 
absolutely contagious. In regard to typhoid fever, it appears to us that the facts 
with which we are acquainted in relation to its etiology would indicate its de- 
pendence upon some inappreciable endemic cause, often limited in extent, and 
upon a peculiar predisposition to its influence, which certain individuals possess 
in a much greater degree than others. We have no doubt, however, that it 
may be communicable under similar circumstances with those which render 
typhus fever communicable. 

The secondary affections common in cases of ship fever, Dr. Clark classes 
under two principal forms, which, although they sometimes run into each other, 
are generally quite distinct : — 

" 1st. General dropsy, which is often accompanied by swelling and sloughing, 
or suppuration of the parotid and other glands, and occasionally by suffocative 
oedema of the glottis. 

" 2d. A diarrhoea or dysentery, which is usually dependent upon inflamma- 
tion and ulceration of the ileum and coecum, and is frequently fatal. 

"1st. The dropsical affection, which we have seen in several cases, after severe 
attacks of fever, is scarcely referred to by authors who have written on the fever. 
It seems to bear the same relation to this fever that it does to scarlatina, and is 
accompanied with suppression of urine. We have known it to be fatal in four 
or five instances out of about three times that number of cases. In two of 
them death was caused by the extension of the disease to the glottis, the general 
state of the patients otherwise precluding any chance of benefit from trache- 
otomy. In one, death followed extensive sloughing of the parotids ; in the 
others the patients were apparently exhausted by an obstinate diarrhoea, with 
which the dropsy was complicated. 

"2d. Chronic diarrhoea and dysentery.— -This most fatal sequel to ship fever 
comes on in most instances, apparently from some error in diet, in the form of 
a slight diarrhoea, which makes its appearance usually towards the close of 
convalescence and after the appetite is pretty fully established. If not arrested 
in this stage, it commonly goes on to a fatal issue, although we have seen a few 
recoveries after a very long continuance of the disease in an aggravated form. 
The patient has, at length, frequent discharges of a thin, yellowish, white, frothy 
liquid, of very fetid odor, which, as the disease advances, becomes sanious or 
purulent ; the tongue is flabby and red, the pulse feeble and frequent, and there 
is great prostration. The pain is not always severe at first, although there 
may be considerable tenderness of the abdomen. In the latter stages it often 
becomes intolerable." 

The important question — What are the pathological changes peculiar to ship 
fever? is answered in the dissertation before us, by presenting an account of all the 
lesions discovered after death in the cases that were examined. This account 
is, however, imperfect — in consequence of no intimation being given of the 
number of post-mortem examinations from which it is derived ; and in conse- 
quence of its furnishing no exact specification of the relative frequency of the 
several lesions described. We present it to our readers in the words of the 
author : — 

"Lesions after death during the acute stage. — These consist, as in other fatal 
exanthems, chiefly of congestions of the various organs, especially of the mem- 
branes of the brain, and the parenchyma of the lungs. The bronchial tubes 
are often found much obstructed with frothy and tenacious mucus. The blood 

1850.] Clark on Ship Fever. 147 

in the heart and great vessels was noticed to be peculiarly dark, fluid, and sizy ; 
its clot large, loose, and easily broken. The lining membrane of the stomach 
is sometimes seen to be reddened, and dotted with clustered points near its 
cardiac orifice, but this was not constant. In cases where the urine had been 
retained, the bladder showed marks of irritation. In the small intestine, the 
internal surface of the ileum sometimes presented traces of inflammation, but 
the pathological condition was more generally limited to a decided injection of 
this part for an extent of three feet or so from the ileo-ccecal valve (without 
disorganization) ; and no case was examined in which this was not observed to 
a certain extent, which varied with the duration of the disease. The same may 
be said of the large intestines also. 

" It must be considered as established, that ulceration of the small intestines 
does not take place in the acute form of typhus ; but that the diarrhoea, which 
happens as a sequel to it, depends upon ulceration, hypertrophy, or inflam- 
mation of the ileum, coscum, or colon. Peyer's glands are usually unaffected 
in any form of ship fever. 

" One important symptom which occurs in some of the graver cases, we have 
not seen mentioned in any treatise. It is, a remarkable retention of urine. At 
the same time, there is no suppression, but rather an increased secretion ; the 
catheter procuring sometimes from three to four pints daily. It is an unfa- 
vourable sign, and occurs mostly in those cases where the nervous system is a 
good deal affected. 

"Another characteristic of this fever is the great indifference which the 
patient manifests in regard to the issue of the disease in his own case and 
in those about him — an indifference which is entirely distinct from delirium, 
and not at all dependent upon it. 

" Tympanitis occurs oftener than is usually supposed; and although the gra- 
vamen of the fever is usually upon the brain and the nervous system, yet there 
are very few cases in which the abdomen is not more or less disturbed. " 

We proceed to notice the treatment which Dr. Clark found most successful 
in arresting the disease, and its sequelae. 

The first and all-important measure is to secure the perfect cleanliness of the 
person and clothing of the patient, as well as of his apartment and bedding, 
and the freest ventilation of the latter. In other words, to remove the patient 
from the influence of the inducing cause of the' fever. 

After clearing the digestive canal, the camphor mixture, with spirits of nitre, 
or the liquor ammonias acetatis, were given during the day, and when there 
was any restlessness, a full dose of Dover's powder at night. Demulcent 
drinks to satisfy thirst. If the bowels were not otherwise moved, a dose of oil 
or magnesia was administered, once in two or three days. If there was delirium, 
accompanied by a hard pulse, the fever mixture of Dr. Stokes was substituted 
for the other. Ice water was applied to the head, and sinapisms to the nucha, 
ankles, or abdomen. If the pulse was depressed, brandy or wine were admi- 
nistered in free doses until the delirium subsided. A blister to the back of the 
neck proved almost a specific in many such cases. Delirium, sometimes of a 
very violent character, was present in many cases which ultimately recovered. 
There was nothing from which the patients derived more comfort than frequent 
sponging of the trunk and limbs during the height of the fever. 

"Local congestions about the chest frequently occurred from the exposure of 
patients on their way to the hospitals, or during the disembarkation, at an in- 
clement season. They were treated mostly by external applications, such as 
epispastics, dry cuppings, &c. In some cases the antimonial treatment, 
combined with local bleeding, was found to be advantageous. But even in these 
cases, which were complicated with severe pneumonia or bronchitis, it was 
often necessary to continue the stimulants at the same time." 

Bleeding, general or local, was seldom thought advisable in uncomplicated 
cases. In the few cases in which it was resorted to, leeches or cups were always 
preferred. Dry cupping often seemed to be of the greatest service in instances 
where the loss of even the smallest quantity of blood was contraindicated. 

The chief reliance of the physician, in a very large proportion of all the 
cases of ship fever, must be upon the administration of direct stimulants. Wine 

148 Bibliographical Notices. [July 

or brandy — the latter of which Dr. Clark prefers in hospital practice — must 
be given, often in the most liberal quantities, measuring them only by their 
effects. The most furious delirium will often be subdued by free draughts of 
wine or brandy and water, and in so short a space of time that the effect seems 
almost magical. Dr. Clark's ordinary dose of brandy was about half an ounce 
to an ounce, repeated usually every three or four hours. 

Camphor, when the nervous system is much disturbed, may be given with 
advantage, in doses of from five to fifteen grains. 

"Quinine is most useful after the acme of the febrile symptoms is passed, 
and will be found to be beneficial in preventing the dropsical sequence of the 

Purgatives are to be used in all cases with the utmost caution. A moderate 
use of calomel may sometimes be required during convalescence, but castor 
oil is better for common use. 

" Some subjects were brought into the hospital in an almost moribund con- 
dition, and unable to swallow. In these cases, stimulating injections were 
administered (per anum). Dry heat, by means of hot flannels, bricks, &c, 
seemed to be of great service in aiding in the restoration of the enfeebled cir- 
culation, and some patients recovered who really seemed, when they first ar- 
rived, to be in a desperate condition. 

"Anodynes. — Opium, in the form of Dover's powder, was almost universally 
preferred as an anodyne, excepting during the secondary diarrhoea, when it 
seemed to irritate the bowels. It was given a great deal, and almost invariably 
with good effect. It is much better borne during the delirium of typhus than 
of typhoid fever. Its sedative effects in most cases were quite direct, and very 
seldom preceded by any period of excitement. Its use is of course improper, 
where there is any tendency to coma. 

" Sulphuric Ether. — This was used by inhalation in a few cases, with very 
good effect" and, "it may become, eventually, a most valuable remedy in the 
delirium and restlessness of fever, when narcotics would be counter-indicated." 

"Anti-septic Enemas are sometimes useful, especially if there is much puff- 
ing up of the abdomen from flatus ; and the common brewer's or baker's 
yeast is a convenient article for this purpose." 

For the diarrhoea, which occurs as a sequel of ship fever, Dr. Clark em- 
ployed a solution of nitrate of silver as an injection, with the application of 
counter-stimulants to the abdomen. The nitrate was administered with a 
glass syringe, to which he sometimes attached J\Jr. O'Beirne's tube, introduc- 
ing thus the solution directly into the colon, and throwing it up from that 
point. In some cases, this treatment was apparently beneficial, in many others 
no treatment availed. Dr. Clark believes it promises as much as any other, 
when combined with the usual opiate remedies. 

During convalescence from ship fever, Dr. C. remarks, a slight indiscretion 
in diet is sure to cause a relapse, or to bring on the fatal diarrhoea. At 
first, light farinaceous food, with porridge, rice, &c, in small quantities at a 
time, are the best articles. Broths and soups are not well borne for a long 
time after recovery has commenced, and their use should be delayed until the 
patient is able to take a little exercise about the house. Dr. C. directs as drink, 
chamomile tea for breakfast and supper, and a little soda water or brandy and 
water for dinner. 

"If the weather is suitable, the patient should be allowed to exercise in the 
open air as soon as he is able to walk ; for nothing in our experience so ra- 
pidly restores the exhausted energies of a convalescent from ship fever." 

As a sensible, practical dissertation upon the leading particulars connected 
with the etiology, symptomatology, and treatment of ship fever, the prize Essay 
of Dr. Clarke will be read with interest and profit. What facts the author has 
adduced in respect to the pathology of the disease are in themselves valuable 
— they are, however, less so than he might have rendered them by employ- 
ing more precision in their detail. So far as they go they would appear to 
favour the doctrine of the specific difference between ship, or typhus, and 
typhoid fevers ; and yet we suspect that the advocates of this doctrine would 
not be inclined to appeal to the dissertation of Dr. Clark for very positive, 
or at least conclusive evidence of its truth. D. F. C. 

1850.] Bell's Dietetical and Medical Hydrohgy. 149 

Art. XXVI. — Dietetical and Medical Hydrology . A Treatise on Baths; including 
Cpld, Sea, Warm, Hot, Vapour, Gas, and Mud Baths: also, on the Watery 
Regimen, Hydropathy, and Pulmonary Inhalation; with a description of Bath- 
ing in Ancient and Modern times. By John Bell, M. D., etc. etc. Philadel- 
phia, Barrington & Haswell, 1850 : 12mo. pp. 658. 

When we consider the importance of bathing in its hygienic as well as thera- 
peutic relations — as a means for the promotion and maintenance of health, and 
for the cure of disease — we cannot but deem it somewhat strange that there 
should exist so few treatises in the English language on the subject — no one, 
in fact, until the appearance of that of Dr. Bell in 1831, of which the present 
may be considered as an extended and improved edition, that presents a com- 
prehensive view of the effects upon the human body of the several varieties of 
baths, " their resemblances and contrasts, and their successive and alternate 

As simple a matter as bathing may appear, and as harmless a fluid as the 
water — cold, warm or tepid — of which the bath is composed — there are few things 
in the use of which more frequent errors are committed — leading often to a 
serious impairment of health, if not to the production of actual disease. Even 
in the application of baths to the cure of disease, there is reason to fear that the 
profession generally are not fully informed of the whole extent of their thera- 
peutical powers, the particular pathological conditions to which the several 
baths are applicable, or the stage and circumstances of the disease to which 
they are individually adapted. 

On every point connected with the hygienic and therapeutical employment of 
bathing, the treatise of Dr. Bell will be found to contain ample instruction, 
based upon correct views of physiology and pathology, and of the effects pro- 
duced by the application of water, at different temperatures, to the body under 
the varying circumstances of health and disease : the correctness of the prin- 
ciples established u.pon scientific data being proved by a reference to the re- 
corded experience of cotemporaneous physicians, as well as of those of former 

Dr. Bell addresses himself to the unprofessional as well as to the professional 
reader. In its hygienic application, bathing is alike important to every one, 
and hence it is essential that the public generally should be informed as to the 
manner in which they may be enabled to derive from it all the advantages 
it is calculated, in this respect, to afford. Even in their use as a remedial agent, 
there exist so many popular errors and prejudices in relation to baths that 
often stand in the way of their full and effectual employment by the physician, 
that to attempt the removal of these by showing to the general reader, the ex- 
perience of the profession as to their propriety and curative powers, may not be 
without good results. 

Dr. Bell, however, warns his readers, that the portions of his treatise devoted 
"to the therapeutical application of baths, or their employment in the cure 
of diseases" are intended "to be exclusively appropriated by his medical 

" High," he remarks, " as his estimate is of the varied uses of water for the wants 
of the animal economy, he does not believe that even this simple fluid can be 
employed with safety and advantage as a remedy, except by persons properly 
qualified to practice medicine. If any advantage could arise to those who are 
not of the profession, from a perusal of the medical portions of the volume, it 
would be, to learn that the practice recommended by their medical adviser, to 
which they might object on account of its supposed novelty and doubtful cha- 
racter — such as, for example, the use of the cold bath in scarlet fever — is sup- 
ported by large and safe precedent." 

We believe that all who attentively study the treatise of Dr. Bell, will 
confess that, while they have been interested by its subjects, and the manner in 
which these are treated by the author, they have also derived no little instruction 
on " the operation and effects of the different kinds of baths on the animal 
economy, as well in its healthy as in its diseased state." It would be a very 

150 Bibliographical Notices. [July 

equivocal recommendation to denominate the work the best systematic treatise 
on bathing in the English language, for, as we have already remarked, it is the 
only one of that description accessible to the great mass of American physicians, 
to whose patronage we strongly commend it. D. F. C. 

Art. XXVII. — The History, Diagnosis, and Treatment of Edematous Laryngitis. 
By Elisha Bartlett, M. D., Professor of the Theory and Practice of Medi- 
cine in the University of Louisville. Louisville, 1850: 8vo. pp. 34. 

This is a well drawn up and highly instructive memoir on the pathology, 
diagnosis, and treatment of a disease of more frequent occurrence than is per- 
haps generally supposed — one which always runs its course with great rapid- 
ity, and terminates very generally in death, unless arrested by prompt and 
active treatment. 

The author was induced to prepare the present treatise, he informs us, in con- 
sequence of there being no full and complete history of Edematous Laryngitis 
generally accessible to American physicians ; the meagre accounts of the dis- 
ease contained in the standard works on the practice of medicine, both English 
and American, being inadequate to furnish that knowledge in relation to it 
which is calculated to lead to an accurate diagnosis and a successful treatment. 

Dr. Bartlett has derived the materials for the preparation of his memoir from 
the most reliable sources, and has employed them in a manner so judicious that 
he cannot fail to receive the thanks of those for whose instruction the memoir 
is designed. He claims no originality in regard to any of the views advanced, 
either pathological or therapeutical, nor has he added" any observations of his 
own, confirmatory or corrective, of those of the authorities he adduces ; neverthe- 
less, in the humble task he has undertaken, of compiling, from the valua- 
ble materials furnished by others, a practical treatise that may reach thou- 
sands who have no access to the information in relation to the formidable dis- 
ease of which it treats, contained in the writings of the continental physicians, 
he may be the means of diffusing information that shall cause the saving of 
many valuable lives. D. F. C. 

Art. XXVIII. — The Life and Correspondence of Andrew Combe, M.D., &c. &c. 
By George Combe. Res non verba quEeso. Philadelphia. A. Hart, late 
Carey & Hart, 1850 : 12mo. pp. 428. 

Few authors, whose writings are chiefly confined to subjects relating to 
physiology and special hygiene, have become so extensively known to persons 
not of the medical profession as the subject of the present memoir. Among 
the thousands whom he has interested and instructed by his works, few will 
be found, now that his active mind and ready pen have been arrested by death, 
without the desire to learn something of " the home life, the daily labours, and 
the character of one who has devoted himself to the improvement of his 
fellow-men, and, if happily it may be, also, as an exemplar, in his own person, 
of the truth of the precepts which he inculcates." 

This natural and rational desire will be fully gratified by the life and cor- 
respondence of Dr. Combe, written and arranged by his brother. The Biogra- 
phy is in itself full of instruction ; in the words of the American editor — " it 
exhibits a man whose childhood was passed in a state neither favourable to 
health, nor to the best culture of the affections, and whose manhood was ush- 
ered in by alarming disease, which, although often remitting in its violence, 
was ever his companion until the day of his death. Yet, notwithstanding these 
adverse circumstances, his mind was gradually developed into a state of ma- 
turity and even vigor, which enabled him, under the impelling power of a 
resolute will and high conscientiousness, to be a teacher and a guide to his 

1850.] Hay ward on the Comparative Value of Anaesthetic Agents. 151 

fellow-creatures, in the means of preserving their health and cultivating their 
intellect, conjointly with the better and kindlier sentiments of their nature. " 

The letters addressed by Dr. Combe to his friends and relatives, either entire, or 
copious extracts from them, are interwoven with the thread of his biography. 
Many of these letters were written by him during his absence from home — 
while seeking, in change of climate and of scene, to arrest the course of the dis- 
ease — consumption — with which he struggled for upwards of twenty-seven 
years. His correspondence embraces a great variety of important topics — The 
effects of different climates on the invalid who is threatened with or actually 
labouring under pulmonary consumption, with minute directions for his con- 
duct, both at home and abroad — Advice and precepts on the ever important 
points of education, national, collegiate, and private — with reference to actual 
wants and adaptation. Great questions of morals and ethics, and the minor, 
but still useful ones of personal deportment and thrift, are brought before the 
reader in his letters to friends, and occasionally in the more formal replies to 
the interrogations proposed to him. Not less pertinent and instructive are his 
remarks and precautions on Public Hygiene, and on the internal economy- and 
government of lunatic asylums. 

In the spring of 1847 Dr. Combe visited America. His account of this visit 
is given in a letter to Sir James Clark. He appears to have been rather fa- 
vourably impressed by what little he saw of the people and institutions of the 
United States — but his stay was too short, and his opportunities of studying 
the features of the country, the nature of its institutions, and the character of 
its varied population, were too limited to enable him to form any just estimate 
of either. 

In America, the writings of Dr. Combe have had a wide circulation, and we 
anticipate that his life and correspondence will be equally popular. No one 
can read them without feeling interested, or without deriving from their peru- 
sal profitable instruction. D. F. C. 

Art. XXIX. — Remarks on tlie Comparative Value of the Different Anaesthetic 
Agents. By George Hayward, M. D., one of the Surgeons to the Massachu- 
setts General Hospital. Boston, 1850 : pp. 11. 8vo. 

In this pamphlet, the author briefly gives the results of his experience rela- 
tive to the particular advantages and disadvantages of sulphuric ether, chloro- 
form, and chloric ether as anaesthetic agents. Dr. Hayward was one of the very 
first to operate upon a patient rendered insensible by the inhalation of sulphuric 
ether, and the numerous opportunities he has since had of witnessing the effects 
of this and the two other named anaesthetic agents, and his matured judgment, 
entitle his opinions to every consideration. 

Dr. Hayward disapproves of all the various apparatus which have been em- 
ployed for the administration of anaesthetics, and prefers for the purpose a bell- 
shaped sponge of fine texture, large enough to cover the nose and mouth. 
This method was first adopted at the Massachusetts General Hospital, and 
is now in general use. The ether should be of the purest kind and admi- 
nistered gradually, and mixed with a sufficient quantity of atmospheric air, 
to prevent the respiration being laborious or painful. "The irritability of 
the parts," Dr. Hayward says, "with which the ether comes in contact is by 
degrees overcome, and then the sponge may be applied directly to the face, 
and if necessary compressed in some measure so as to exclude to a greater 
degree the atmospheric air. When the desired effect is produced, which is 
usually in from three to five minutes, the patient has no control over the 
voluntary muscles ; he cannot speak ; he cannot open his eyes when directed 
to do so ; his muscles become completely relaxed, and the pulse, which at the 
beginning of the inhalation is frequent and often rises during the process to 
one hundred and forty beats in a minute or more, becomes slower, and I have 
very often known it to fall to sixty. The patient is then insensible and uncon- 
scious, and the surgeon may begin his operation with great confidence that he 

152 Bibliographical Notices. [July 

will inflict no suffering. The sponge should then be removed, and reapplied 
from time to time as circumstances may require. If the ether is not pure, 
longer time is necessary to produce the desired effect ; the brain and nervous 
system are more excited, and the patient is occasionally violent for a time and 
with difficulty controlled. 

" Before using the ether the sponge should be dipped in warm water, and then 
strongly compressed, leaving it slightly damp. The evaporation seems to go 
on better in this way, than when a sponge is used that has not been previously 
moistened. In the first instance, the ether should be poured on the inside of 
the sponge ; about two ounces is enough ; when more is required, it should be 
applied to the outside, as it is best not to remove the sponge from the face." 

Sulphuric ether used in this way Dr. Hay ward confidently believes to be "per- 
fectly safe, and will in almost every instance produce the desired effect. I have 
administered it to persons of all ages, of every variety of constitution, and in 
almost every state of the system, and I have never known in a single instance 
a fatal or alarming result. I have given it to infants of seven weeks old, and to 
individuals of seventy-five years with entire success. I have administered it to 
persons suffering under chronic pulmonary disease, not only without injury, 
but in some cases with decided benefit. It is well known that it often gives 
relief in catarrhal affections of the lungs and in paroxysms of asthma. In fact, 
I hardly know a state of the system in which I should be deterred from using 
it, if I were called upon to perform a surgical operation." 

The advantages of sulphuric ether are, according to Dr. Hayward, "its entire 
safety, the ease with which it is administered, and the slight inconvenience 
which follows its administration. I have already stated that I have never known 
its inhalation followed by a fatal or alarming effect, and there is reason to doubt 
whether death has in a single instance been produced by it, when it has been 
properly administered. One patient is said to have lost his life by its inhalation 
at the hospital in Auxerre, in France. This took place in August, 1847. The 
details of the case are not given with such minuteness as to enable any one to 
form a satisfactory opinion. It occurred, however, not long after the discovery ; 
before the best mode of exhibiting it was adopted, and the post-mortem appear- 
ances indicated, as far as any opinion could be formed from them, that death 
was caused by asphyxia. In a careful examination of some of the leading 
medical journals of Europe and this country, published during the last three 
years, I have not been able to find another case in which life was destroyed by 
the inhalation of sulphuric ether, and there is reason to believe, as I have 
already intimated, that death would not have taken place in this instance, if 
the lungs had been abundantly supplied with atmospheric air. It is only 
wonderful that an agent of such power, used as it often has been in the most 
reckless manner, by unskilful and ignorant persons, should not have caused 
far more disastrous results, than any that have hitherto been made known. It 
teaches us that though it should be used with caution and confided only to 
skilful hands, the dangers from its use are far less than our preconceived 
opinions had led us to believe. 

" There are no ill consequences from its use. If it be breathed only for a short 
time, its effects usually pass off in a few minutes. I have never known them to 
continue for more than an hour ; and in this case the patient had been kept 
under its influence for forty-five minutes. Nausea and vomiting are not fre- 
quent, unless it is inhaled soon after food has been taken. I have not seen 
convulsions follow its exhibition, nor any delirium, except a slight and transitory 
kind, such as arises from intoxicating liquors. I confess that I was much sur- 
prised to learn, by carefully watching its effects, to what a small extent and for 
how short a time it disturbed the functions of the nervous system, and how rare 
it was to find headache among the consequences of its inhalation. 

" If, however, the state of narcotism should continue longer than is necessary 
for the purposes for which it was produced, the means that seem to me the most 
likely to remove it, are the dashing of cold water in the face; the application 
of strong stimulants, as the carbonate of ammonia to the nose ; and as soon as 
the patient can swallow, the administration of a small quantity of hot spirit 
and water. The object is to increase the action of the heart, so that the blood 

1850.] Hay ward on the Comparative Value of Anaesthetic Agents. 153 

may circulate more rapidly through the lungs, and thus be enabled to part with 
the vapour of the ether that is mixed with it. When narcotism arises from any 
noxious substance taken into the stomach, we adopt means to empty that organ 
as soon as possible by the stomach-pump or an emetic. The principle of the 
treatment in the two cases is the same ; the object being in both to remove the 
cause of the peculiar state of the system under which the patient is labouring. 

" The only objections of which I am aware to sulphuric[ether as an anaesthetic 
agent, are its pungent odour, which is offensive to some persons, and the no 
inconsiderable degree of irritation which its inhalation occasionally produces 
in the air passages. This irritation, I am confident, may be in great measure 
prevented by proper attention to. the mode of its exhibition and the quality of 
the article used. Admitting these objections to be as great as they have been 
said to be by those who have urged them with the most earnestness, they do 
not in my opinion counterbalance the advantages ; and I have no hesitation in 
saying that I should give it the preference over any other article with which I 
am acquainted, that is used for the purpose of producing insensibility." 

The only advantages which chloroform possesses over sulphuric ether, Dr. H. 
states, " are that it is more agreeable to inhale than ether, and that a less quan- 
tity of it answers the purpose. On the other hand, it cannot be denied that 
fatal effects have followed its inhalation in several instances, even when ad- 
ministered by the most judicious hands ; that in some cases convulsions have 
been produced, and in others a great disturbance of the brain, causing delirium. 
In some persons, this affection of the mind has continued for several weeks. 

" There are other objections of a minor character. Chloroform is of an acrid, 
caustic nature, and if it come in contact with the skin, unless it be protected 
by some oily substance, severe excoriation is the consequence. Its administra- 
tion is generally followed by vomiting and headache, which continues for 
several hours, attended by a great degree of restlessness and want of sleep. 
Several cases have come under my care, in which the brain aud nervous system 
have been affected to an alarming extent ; though, in every instance, it was said 
that small quantity only of chloroform was administered for the purpose of 
performing some operation on the teeth. 

"An individual in this vicinity was thrown into violent convulsions, which 
continued for three or four days, during all which time she was in a state of 
complete insensibility, from the inhalation of the vapour of a few drops of 
chloroform administered by a careful and judicious physician. It would be 
easy to multiply examples of this kind ; but it is not necessary, for there is a 
stronger ground on which we can rest our opposition to the use of chloroform, 
that is, its danger to life. This, it is well known, has already been in several 
instances destroyed by it. If it can be shown that it has caused the death of a 
single individual, when properly administered, we cannot fail to have our mis- 
givings of the safety of its exhibition, though it may have been inhaled in 
almost numberless cases without any ill effect. 

"I am satisfied that there are already on record at least twenty well-authenti- 
cated cases of death from the inhalation of chloroform ; and I know not how a 
conscientious man, knowing this fact, can willingly take the responsibility and 
expose his patient to this fearful result. One of the conclusions to which M. 
Malgaigne arrives, in his report on chloroform, to the Academy of Medicine of 
Paris, cannot be too strongly impressed on the minds of those who feel inclined 
to use it. ' Chloroform possesses a toxic action peculiar to itself, which has 
been taken advantage of in medicine by arresting it at the period of insensi- 
bility, which action, however, may, by being too much prolonged, cause imme- 
diate death.' The danger is that we cannot always know the precise time to 
arrest it, and that the fatal blow may be struck before we make the attempt. In 
other words, chloroform is a poison, and the insensibility which it produces is 
only the first stage of its poisonous action." 

The chloric ether consists of one part of pure chloroform, with nine parts of 
alcohol. This, "it cannot be denied/' says Dr. II. "derives its power of pro- 
ducing insensibility from the chloroform it contains ; and it is difficult to 
understand how the addition of alcohol can deprive it of its dangerous proper- 

154 Bibliographical Notices. [July 

ties, when it is well known that the mixture of this substance with sulphuric 
ether renders it in great measure unfit for inhalation. 

"The advantages which it is said to possess are, that its odour is less pungent 
and disagreeable than that of sulphuric ether, and that it can be inhaled with 
little or no inconvenience. At the same time, it must be admitted that it is ne- 
cessary to use as much chloric as sulphuric ether, and to continue the inhala- 
tion for as long a time to produce the desired effect. 

"The disadvantages are, that when it comes in contact with the unprotected 
skin it acts upon it in the same manner as chloroform. From this cause a 
patient suffered several months at the hospital, and I believe much more se- 
verely than if he had undergone the operation without the ether. I am confi- 
dent, too, that it is more apt to produce vomiting, and a greater disturbance of 
the brain and nervous system, causing headache, restlessness and vigilance, 
which not unfrequently continue for many hours after its exhibition. Perhaps 
these last symptoms may be owing to the great amount of alcohol it contains. 

"I cannot, I confess, divest myself of the belief that chloric ether is an unsafe 
anaesthetic agent, when I consider that it is simply chloroform diluted with 
alcohol. It is true, that as far as we know, no fatal effects have hitherto fol- 
lowed its inhalation ; but it is also true, that it has as yet been used to a very 
limited extent, and in all the cases in which it has been exhibited that have come 
to my knowledge, it has been managed with great caution and judgment. But 
I fear that if it be used with the same freedom that sulphuric ether is, we shall 
soon have to record some very different results. We cannot feel confident that 
it will always be confided to skilful hands only, nor by any means certain that 
death, when not looked for, may not follow its exhibition." 

If all surgeons would narrate as candidly as Dr. Hayward has done, the 
results of their experience, with different anaesthetic agents, we should soon be 
able to form a just estimate of their value. 

Art. XXX. — Physic and, Physicians. The Annual Address delivered before the 
Alabama State Medical Association. By William 0. Baldwin, M.D. Mont- 
gomery, 1850: pp. 43, 8vo. 

The first portion of this Address is occupied in refuting the statement so 
frequently made that the profession has degenerated, and the second in de- 
ploring the ravages of quackery within and without the profession. The two 
are scarcely consistent with each other. The author has, like many others, 
confounded the improvement of medical science, which nobody contests, with 
the improvement of medical practitioners, which nobody has demonstrated. 
He says : " whoever observes the character and success of the profession, as 
organized and operative in our day, can hardly avoid the conclusion that any 
given number of young men who now graduate in the United States, are better 
qualified than the same number were in any preceding year." 

That is not, we respectfully submit, the question at issue. It is most cheer- 
fully conceded that in those schools which, twenty years ago, sent out their 
three or four hundred graduates annually, the graduates of every subsequent 
year have progressively improved, partly in consequence of their previous edu- 
cation being better, and partly because the medical courses have been per- 
fected. But what shall we say of a large portion of the six or eight hundred 
annual graduates who are now poured out by more recently established insti- 
tutions ? W^e are persuaded that in average attainments they do not reach 
the standard of graduates of twenty years since ; and, what is worse, that after 
entering the profession they are much more apt to remain stationary. For 
while in the olden time the student was at least impressed with the dignity, 
excellence, and sacredness of his calling, the class of modern students to which 
we have allusion become physicians with such motives as ought to lead them 
to be blacksmiths or carpenters, or members of some fraternity in which they 
might be really useful to mankind. But they take up physic as a trade, they 
are taught by traders in diplomas, and they practise in the true spirit of 

1850.] Baldwin's Address on Physic and Physicians. 155 

tradesmen. And as for improvement — they vote all discoveries a humbug, and 
study a bore. Yet these persons, physicians in name, and by virtue of a parch- 
ment title, claim and assert an equality of rank with the well-educated, the 
high-minded, the studious, and progressive members of the profession. They 
form a part of the same body politic, and by their character and conduct de- 
termine its estimation in the world. Twenty years ago nearly all graduates of 
medical schools were sure to possess a respectable degree of knowledge and 
skill ; but now, although the graduates of a certain number of schools have 
higher attaiments than ever, the remainder occupy the very lowest point in 
the scale, which begins at the zero of ignorance and ends at the climax of 

We repeat, then,, that owing to the very large proportion of incompetent per- 
sons annually admitted into the ranks of the profession, it must, as a body, be 
held to have degenerated ; while at the same time the number of accomplished 
graduates is every year increasing. Thus it happens that the diploma alone 
is no evidence of competency : its source decides its value. Coming from one 
quarter it affords presumption of its owner's ignorance ; coming from another 
source it gives assurance that its possessor has at least had the opportunity of 
becoming a competent physician. It had perhaps been well for the author of 
this Address to consider these things before asserting " that much of what 
has been said recently in relation to our Medical Schools, are untruths." 

We find little room for dissent from the author's remarks upon quackery, 
some of which a#e very much to the point. For instance : "Persons, in this 
strange world, frequently have more power than either truth or fact ; and con- 
sequently, the legitimate instrumentality of a physician is oftener interrupted 
by the unwise and unjust intermeddling of others, than by any other agen- 
cies." This we conceive to be the kernel of the whole subject. It is not by 
reason that medicine can be assailed ; the raging vice of the times, the itch 
of people to give opinions upon all possible subjects, and most especially upon 
those they know nothing about, that is the secret of quackery in politics and 
religion, as well as in medicine. 

" Men," says Dr. Baldwin, " whose opinions or judgment we would value 
highly on any of the ordinary affairs of life ; men who are distinguished 
for their good sense and philanthropy, and who are deeply learned in all 
that pertains to their own calling, are generally profoundly ignorant of all the 
requisites necessary to a just and enlightened view of ours. . . . Yet it is 
true that such men often lead public opinion in matters directly affecting the 
science of medicine." 

A notable instance happens to present itself while we are writing. In an 
article on " authority in matters of opinion," contained in the Edinbugh Re- 
view for April, 1850, the writer says that homoeopathy is plausible. The reason 
is a curious one. "The homoeopathist," he remarks, "tells us that much of 
what we call disease is, in fact, a curative process. That the acceleration of 
the pulse, for instance, in fever, is an effort of nature to escape from a mis- 
chievous influence," &c. Think of a doctrine being attributed to homoeopathy 
which has been that of the whole medical world, with trifling exceptions, from 
the time of Hippocrates to the present day ! And yet such blunders, and 
worse, are made perpetually by the would-be critics of our science. 

The Address before us contains many sound views respecting the various 
medical impostures which are in fashion just now, and very properly cautions 
those who heard it against attaching to them undue importance, or suppos- 
ing that they can exert any permanent influence on the condition and pros- 
pects of the medical profession. Such arguments are undoubtedly useful ; 
but they would be quite unnecessary if our physicians were as familiar with 
the history of medicine as they would become under a different system of 
education from that which now prevails. A. S. 

156 Bibliographical Notices, [July 

Art. XXXI. — Production of Vital Force. By Edward Jarvis, M.D. 8vo. pp. 
77 : Boston, 1849. 

This paper was delivered as an Address before the Massachusetts Medical 
Society, and composes nearly the whole of the first number of the eighth volume 
of their published proceedings, at their annual meeting in 1849. It will be 
read with much interest by all who give attention to vital statistics, since 
it demonstrates facts of the highest importance to the welfare of individuals 
and communities. 

The application of accurate arithmetical tests to show the proportions of sick- 
ness and mortality experienced by persons of different classes and pursuits, 
at different ages, has opened the eyes of many of the most intelligent, 
and invested the subject of vital statistics with great consequence, although 
not yet with all the importance it deserves. We say this because we find 
other matters of far less consequence to human welfare — those, for example, 
connected with pecuniary affairs, receiving much more attention from indi- 
viduals and communities, and absorbing much more time and attention from 
legislative bodies. Such labours as the one now before us will do a great deal 
towards enlightening many who have hitherto been more or less blind to the 
evils besetting humanity in its different aspects, and who have not been 
aware of how much may be done to lessen the amount of sickness, alleviate 
suffering, and prolong life. • 

Dr. Jarvis describes the human constitution as made up of the aggregation 
of all the physical powers, the original organization, the united energies of the 
nutritive, respiratory, cutaneous, locomotive, and nervous actions, and the 
predominance of the vital over the chemical affinities, co-operative in the 
production of vital force. These make up the constitution of man, or capacity 
for labour and endurance, as well as power of resisting injurious influences. 
This quantum of vital force he regards as the capital of life, with which human 
beings operate in all their works and actions, whether of utility or pleasure. 

" Some few persons," he observes, "have only vital force sufficient to barely 
sustain life. They can digest their food, and perform the other functions ne- 
cessary for the replenishment of the exhausted powers, and no more. They 
can only keep their vital machines in operation. But most persons have more 
than this. After supplying their natural wants and raising the power of the 
machine to its highest healthy point ; then deducting all the vital force neces- 
sary for these from the whole constitutional force, there is in them a surplus 
of energy left to be disposed of otherwise ; and this may be expended at their 
own will, in action of the muscles or of the brain, for profit or for pleasure." 
This surplus energy is regarded as the income of life,' which, may be expended 
daily and yet leave the capital unimpaired. The daily expenditure must, 
however, be limited to the quantity of vital force generated by each day's nu- 
trition and each night's sleep. 

That every error in life produces its proportionate diminution of vital force, 
is an axiom generally admitted. "The capital of life," observes Dr. J., "and 
the capital in trade are both subject to somewhat similar conditions ; and both 
are diminished by every error. As with the merchant, every disadvantageous 
investment, every neglect of the means of due profit, every expense in the con- 
duct of business beyond what is necessary for its success, and every other ex- 
penditure beyond the income, lessen the amount of his pecuniary capital ; so, 
every neglect of the due means of recuperating life, every failure of proper 
food, in time or in quantity, every tax upon the digestive organs beyond what 
the nutrition of the body requires, every inhalation of weakened or vitiated 
air, every excess of labour by muscle or by brain, every privation of sleep, all 
expenditure of power beyond the average daily strength — each one of these, 
whether great or small, diminishes, in its proportionate degree, the vital 

The effects of errors in living are regarded as accumulative, perhaps im- 
perceptible at first, but in the end certainly displayed with greater or less 
gravity. These are glanced at as they appear in the too intense student, epi- 

1850.] Jarvis on the Production of Vital Force. 157 

cure, overtasked man of business and operative, the dwellers in too-crowded 
apartments, buildings, or localities, etc. etc. " There is in man," says Dr. 
J., " a large vital capital, to be expended, a large power of endurance that 
may be exhausted in wrong management ; and, therefore, he does not regard 
his errors, nor perceive his losses. But all undue expenditure is none the less 
a loss, and all endurance is weakening ; and the day of reckoning and suffer- 
ing, sooner or later, inevitably comes. The consequences grow out of and 
hang upon the causes, and they cannot be separated. 

" It is plain, then, that the separation of perfect health from acknowledged 
sickness is not by a distinct and narrow line, on one side of which all is sound- 
ness, and on the other, indisputable disease. But between perfect health — as 
good as the original constitution admits — and recognized disease, there is a 
wide space, a sort of neutral or disputed ground, occupied in part by both, and 
exclusively claimed by neither. 

" The result of all this variety of organization, development, and self-ma- 
nagement is, that between the strongest and the weakest man, both in the en- 
joyment of their average, or what they call good health, there is an interval 
almost as wide as that between life and death ; and, in this wide space, there 
is every grade of power in which men live and enjoy all that they suppose is 
allotted to them. Whatever the grade may be in which any one stands, that 
is his own standard of health, in which he hopes to sustain himself, and thinks 
himself sick only when he falls below it." 

The depressing causes operating in reducing the standard of health often 
continue their wasting work until they constitute predisposing causes to dis- 
ease, or even some positive morbid change. And these ills flowing from the 
errors in life adverted to, are observed most frequently among the poorer 
classes, exposed to privations and other evils, among the weak and foolish who 
mismanage themselves, and the wicked who abuse themselves. Villerme, the 
eminent French statician, observes that, in some parts of France, the mortality 
among the indigent is just double that of the wealthy, and that taking to- 
gether the whole French population, human life is protracted twelve years and 
a half among the wealthy beyond its duration among the poor. "Sickness 
and mortality," observes Dr. Jarvis, " seem to go hand in hand with poverty. 
The want of intelligence and skill in self-management accompany the want of 
pecuniary means to procure the comforts and even the necessaries of life. 
Poverty refers to vitality and to bodily and mental health, as well as to es- 

Some of the most striking and startling results are furnished in the re- 
ports of the British Registrar-General, of the different proportions of mortality 
observed in different classes. From classifications made in different towns and 
places, according to occupations and domestic conditions, it appears that in 
the families of the prosperous, 20 per cent., and in the families of the poor, 
50 per cent, of the deaths were under 5 years of age. Of the prosperous 28 
per cent., and of the poor 66 per cent, died under 40. Among the prosper- 
ous 46 per cent., and among the poor only 8 per cent, survived their 60th 

In considering the causes of the differences of vitality, Dr. Jarvis thinks 
much depends upon difference of organization — much upon development — but 
most of all upon self-management. The last, he says, is certainly within the con- 
trol of man himself; the second within the control of his parents ; and the first, 
more under the control of the world than persons are generally willing to 

"There is," he very justly remarks, " a general ignorance of the laws of vi- 
tality. Men do not understand the connection between their conduct and vital 
force ; and they feel but little responsibility for the maintenance of health. 
They lay their plans and carry on their operations without much regard to the 
conditions of their existence. Life and its interests are not always paramount 
considerations ; but they are made subordinate to matters of inferior importance. 
They are sacrificed or made to yield to common conveniences and concerns : a 
man postpones his regular meal, or perhaps goes without it, for want of time to 
attend to it; or, he eats too much, in order to gratify his appetite, or perhaps 
No. XXXIX.— July, 1850. 11 

158 Bibliographical Notices. [July 

to please his friends ; he exposes himself to inclement weather — cold, storms, 
and heat — in pursuit of pecuniary profit; he fashions and wears his clothing, 
not according to the necessities of his temperature, but according to the vary- 
ing taste of the world ; he works late at night, or early in the morning, and 
expends in the day more vital force than the night brings back to him ; or, he 
devotes some of the hours needed for sleep to pleasure, or to the calls of 

"In the management of the organs and powers, the question, generally, is 
not — What does life require for the development and maintenance of its fullest 
power? but — What will it bear without extinction? Doubtful questions are 
determined against life, which must bear the risk of the loss/ 7 

Dr. Jarvis makes many judicious remarks in relation to the different care 
bestowed upon measures relating to the preservation of life and health, and 
those connected with property, and views the influence of parentage on the 
constitution. Upon this last topic he observes that " hereditary strength or 
weakness must be traced back to the marriage relation for its cause. There it 
may not be possible to interfere. It is apparent that we cannot apply some of 
the means for the improvement of the human race that we do for the improve- 
ment of the lower animals' and vegetables, by the selection of parentage. 

"The sensibilities of society would revolt at the thought that only the healthy 
should marry. Mankind love to cherish some peculiarly holy and delicate no- 
tions in respect to marriage; the tenderest feelings of the heart, and the uncal- 
culating affections, seem exclusively to be considered. People seem to marry 
for their own happiness alone, and cast no look beyond themselves. Yet other 
considerations are sometimes admitted. None can be blind to the future fact, 
that from this institution another generation shall spring ; and, although these 
future events are forbidden subjects of discussion with those who are most in- 
terested, and even all allusion to them in their presence is studiously avoided, 
yet, in reference to pecuniary matters, the probability of issue is occasionally 
considered. Some cautious women, in order to prevent the loss of their own 
estates, in the chances of their prospective husbands' affairs, secure it before 
marriage to themselves and their issue. And some prudent persons, before 
contracting marriage, would consider it unwise to neglect to ascertain whether 
the proposed partner had merely a life right in an estate in possession, or 
whether the estate was held in fee simple and would descend to the possessor's 
children. And so men and women do not hesitate to look at the probability of 
offspring when money is concerned, and to provide in the advance for the se- 
curity and sufficiency of their estates. 

"If the world could be convinced that health and strength descend from 
parents to children as certainly as property, and that the laws of man cannot 
guarantee to the future offspring the possession of estates that now belong to 
the contracting and marrying parties as effectually as the laws of nature 
guarantee that their organization, and the physical, mental, and moral quali- 
ties that grow out of it shall descend to their issue ; if this law of hereditary 
life could be as generally understood as the law of hereditary property, then 
men and women, in their matrimonial selections, would take into consideration 
the constitution and health of their proposed partners. And those who now 
think it wise to ascertain whether wealth or poverty shall be entailed upon 
their children, would think it still more wise to ascertain whether a sound 
constitution, or insanity, epilepsy, consumption, scrofula, rheumatism, or any 
other disease shall be their children's inheritance. Certainly no prudent man 
or woman can know that any one of these diseases, or that defect of organiza- 
tion which creates a susceptibility of any of them, belongs to the proposed 
husband or wife, without shrinking from the connection that would entail it 
upon their own children. 

"It is an essential element of our highest benevolence and cultivation to 
arrange all our plans of action in such a way that they will secure the greatest 
good, not only for the present time and for ourselves, but for the future and for 
all others that may be affected by them, however remotely. On this principle, 
wise and generous men and women, when they form their matrimonial plans, 
will look, not merely for those qualities of mind and heart that will give the 

1850.] Townsend's Address on Dental Surgery. 159 

greatest present enjoyment to themselves, but for all those qualities that will 
secure the greatest and most permanent enjoyment to their children and their 
remotest posterity. 

" For this purpose, it is necessary to learn, first, the law of hereditary descent, 
and, next, the facts in regard to the hereditary or acquired constitution, the 
present health, and the purity or impurity of the blood of those who are candi- 
dates for matrimony. When used for this object, the study of even 'endless 
genealogies' will be profitable ; not for the mere purpose of finding a series of 
names that represent a succession of generations, nor of tracing out some root 
of external honor, but to determine through whose veins the blood has flown 
from even remote ancestors to the present generation. 

" In this view, the registration of births, marriages and deaths becomes of 
great value, for it will show from whom any one is descended, what families 
have connected themselves with his family, who have contributed the elements 
of their life to the formation of his life, whether any taint has crept through 
any of these channels into his blood, and what fatal diseases have been in his 

Dr. Jarvis thinks that the vital forces of human beings are susceptible of 
similar increase to what is observed in the vegetable kingdom and the inferior 
animals. The most forbidding fruits by careful cultivation have been changed 
into those of most delicious qualities, whilst animals have been so improved by 
judicious attention as to appear almost of a different species from the primitive 
stock. In regard to the prospects of improving the human family, and the 
number of ages it will require for mankind to attain to its fullest development 
and measures of vitality, Dr. Jarvis does not venture any rash conclusions : but 
nothing is more certain than that conspicuous beneficial changes will follow 
the adoption of all judicious measures resorted to for improving the physical 
condition of man, and lessening the amount of his sickness and suffering. 

G. E. 

Art. XXXII. — Opening Address delivered before the Society of the Alumni of 
the Baltimore College of Dental Surgery, at the Second Annual Meeting, March 
26th, 1850. By E. Townsend, D. D. S. 

The rank which dentistry has assumed within the last few years, as a branch 
of surgery, like the corresponding position of pharmacy as a department of 
medicine, is a strong proof of the advancement of scientific knowledge, and of 
the tendency which the scientific culture of any subject possesses of elevating 
those who pursue it zealously. What chemistry has done for the pharmaceuti- 
cal profession, anatomy, physiology, and pathology have accomplished for that 
of dentistry ; until both were linked with science, both were the chosen fields 
of charlatanism, and held in light esteem both by the public and by physicians. 
But now they have attained a form and dimensions which daily bring them 
closer to our own profession, and obtain for them, in our public convocations a 
recognition of their rank, which is all the more courteous that it is entirely 
just. It gives us pleasure, therefore, to witness the continued development of 
the organization under which the dentists of the United States have become a 
scientific body, and to receive such evidence of their being animated by a true 
and generous spirit as this address presents. Our readers may judge of the 
sound sense and high tone of this production, from the subjoined extracts. 
Except one or two historical errors in relation to the origin of medicine and 
surgery, it contains little that suggests unfavourable criticism, but much on 
the other hand which physicians, as well as dentists, might reflect on with ad- 

Speaking of association as a means of diffusing knowledge, the author makes 
these striking remarks : — 

" It is in the nature of mind to impart most liberally its most valuable acqui- 
sitions, and to receive with an equally unselfish avidity all that the social com- 
merce of intellect returns, just as light is transmitted and reflected from gem to 

160 Bibliographical Notices. [July 

gem in multiplied brilliancy, and as the vivifying rays of solar heat flash from 
object to object, till an equilibrium of the blessings give repose to the distri- 
butive impulse. It is only the lower relishes of the animal appetites that can 
enjoy a solitary feast. The raptures of the higher intellectual, and of the 
nobler moral, faculties are all found in a generous munificence, which emulates 
the ' prodigality of heaven/ This is not only the natural religion, but it is also 
a natural necessity of the intellect, for by a paramount law of human education 
it is ordained that by giving we shall receive, and in teaching we shall learn. 
To seize, to hide, and hoard are the only means of accumulation which the 
lowest instincts know, and it is not given to the shut soul and cavern heart to 
comprehend the divine policy of those high natures which acquire only to be- 
stow, enjoy only what they spend, and lay up their chiefest treasures by giving 
them away." 

And, again, of the duty of publishing discoveries : — 

" If you do make discoveries — if nature and education have made you great 
enough for that, be not mean enough to run away into the dark with it ; skulk 
not out of good company to fatten on your good fortune, for recollect that you 
have borrowed as much from the liberality of others as your own genius will 
ever repay to the great world of science. 

" If there be anything revealed to you, give it to the light, that others may 
interpret, and test, and prove it. Recollect that the apostles of science have 
all things in common, and if you meanly secrete a part of the wealth which 
belongs of right to the general stock, you deserve to be carried out of the pro- 
fession, like Ananias, feet foremost ." 

That the operator does not make the surgeon is thus admirably illustrated : — 

" Mechanical skill and expertness of manipulation do not make a dentist, 
though all operations absolutely depend upon dexterity of hand ; for our pro- 
fession is a science as well as an art. Like statuary, it involves taste as well as 
tact ; like surgery, it involves knowledge, as well as skill ; and like remedial 
science in general, it demands systematic knowledge broadly based in anato- 
mical facts, physiological laws, and medicinal agents. The acquirement of our 
professional learning requires a scholar ; its practice requires an artist ; and its 
standing and social relations demand a gentleman." 

We commend the following observations to those of our surgeons, who, like a 
certain eminent Frenchman who carried a case of instruments to a medical con- 
sultation, seem to think that " il y a toujour s quelque chose a couper." 

" I am not ashamed of my workmanship, nor do I refuse the credit it gives 
me ; but the man who will teach me how to save a tooth that I am now obliged 
to sacrifice, is my master in the science of dentistry, without the proof of any 
other claim, and I gladly yield him the post of honour. 

" First principles in advance of all experience assure us that all which en- 
ters into the art of prevention, preservation and cure, must take precedence of 
that which only mutilates, substitutes, and replaces." 

A common idea that the decision of an eminent man, or learned body of men, 
is final in scientific questions, is thus happily refuted — 

'• Speculative truth and the resulting practice lie within the domain of 
opinion, which is by nature free, and cannot be brought into bondage to any 
man, or any number of men. Moreover, it is not necessary that all questions 
should be settled and ended ; it is necessary only that the truth should be 
known, and when every man has given his testimony faithfully he has done his 
whole duty ; a step farther, and he is trespassing on the rights of others. 
Settling a question of opinion by authority is only in fact «msettling a great 
principle, by arresting inquiry, and forbidding future experience to illustrate 
and modify the past. Science is not a despotism, and its real cultivators are 
all equally freemen, and their liberty is as essential to the progression of truth 
as it is to individual honour." A. S. 

1850.] 161 







1. On the Pelvico-Prostatic Ligament, or the Apparatus by which the Bladder, 
Prostate, and Urethra are attached to the outlet of the Pelvis. — A memoir on 
this subject, by Retzius, which was originally published in Stockholm, and 
translated by Fr. Creplin, into Miiller' s " Archiv.," gives a very lucid account 
of a region most interesting to the anatomist and surgeon, and we present our 
readers with the following abstract of its most important details. 

The author — after alluding to the once-received doctrine that there existed 
a constrictor of the bladder, and to the observations of Santesson which dis- 
proved this doctrine — directs attention to the muscular apparatus surrounding 
the urethra, described by J. Miiller and Santesson : a structure consisting of 
oblique muscular fibres, analogous to those of the oesophagus and intestines. 
The muscles described by Wilson are, Retzius thinks, less constant, and are 
not always to be found on dissection. In the work in which Miiller described 
the "constrictor isthmi urethralis" (Berlin, 1836), he also made mention of 
the two important ischio-prostatic ligaments. These structures are of consi- 
derable strength, and extend from the ascending rami of the ischium to the pos- 
terior lateral parts of the prostate. Santesson regards these parts somewhat 
differently from Miiller. He views their attachments to the ascending rami of 
the ischium, and to the descending rami of the pelvis, as a tendinous arch, to 
which the constrictor urethrse is fixed. Anatomists are much indebted to 
Miiller for having called attention to these important structures ; for he, too, 
considered them as something more than mere ligaments. They are the cord- 
like and concave hinder edges of a peculiar fibrous capsule, which embraces 
not only the prostate, but likewise the membranous, portion of the urethra — a 
capsule which performs the part of an important ligament, and which, in its 
cord-like edges, includes the muscular fibres described by Santesson as the 
longitudinal fibres of the constrictor urethrse. 

Hyrtl endeavoured to show that the so-called constrictor was, in fact, more 
than a mere constrictor. The author agrees with him in considering the fibres 
which pass from the pelvis to the urethra as part of a very complicated mus- 
cular apparatus, destined to act upon the membranous portion of the urethra, 
not as a constrictor, but as an ejaculator seminis, as a compressor of Cowper's 
glands, and an assistant in the expulsion of urine. He believes that the cir- 
cular muscular stratum of the urethra constitutes the true constrictor, and that 
the function of the longitudinal fibres just alluded to is in exact antagonism. 

The only writer who has described the fibrous structures about the prostate 
as a capsule is Denonvilliers ("Propositions et Observations d'Anatomie, de 
Physiologic, et de Pathologie," Paris, 1837 ; article 3ieme, "Anatomie du 
Perinee"). He finds fault with the ordinary mode of describing the fascise, 
without regard to the parts to which they actually belong, and endeavours to 

162 Progress of the Medical Sciences. [July 

show that every muscle has its fascia, just like every great blood-vessel and 
every important organ in the body, as the larynx in the neck and prostate in 
the perineum. His words, where he treats of the latter organ, are as follows : 
" The prostate and membranous portion of the urethra are situated in the 
centre, included within the superior, inferior, and lateral fibrous planes, enve- 
loped on every side, and sheathed like muscles We can conceive 

the membranous portion of the urethra to be contained in a species of irregu- 
larly-quadrilateral case." 

Retzius had for several years been accustomed to teach a similar doctrine ; 
but he attributes certain uses to the pelvic fasciae, which are not alluded to by 
Denonvilliers. We extract his description entire : — 

Ligamentum Pelvio-prostaticum Capsulare. — The thin membrane which covers 
the urinary bladder, which has commonly been described as apart of the pelvic 
fascia, and which passes outwards into the substance of the arcus tendineus 
of Santesson, stretches from the lower part of the bladder over the prostate. 
On reaching this organ, it becomes thick, and adheres firmly to the gland. The 
anterior part of the levator ani is in close apposition with this capsule, and no 
fascia intervenes between them. The capsule is thinnest at the posterior sur- 
face of the gland, passes down between it and the rectum, is prolonged beneath 
the prostate, covers the back part of the muscular apparatus of the urethra, 
as well as the included glands of Cowper, stretches sidewards to the ascending 
rami of the ischium, to which it is attached ; and between these attachments 
a thin layer passes down behind the bulb of the urethra, and terminates by 
a sharp reflection in the so-called triangular ligament. At the sides of the 
prostate, where the capsule is strongest, it stretches outwards, and is fixed to 
the neigbouring rami of the ischium and pubes. Thus the sides of the capsule 
are spread out like a tent, leaving the substance of the gland and covering the 
plexus venosi pudendales, with the accompanying arteries and nerves. Its 
attachments to the sides of the pelvic opening extend from the horizontal rami 
of the pubes almost to the tuberosities of the ischia. The anterior margins of 
these lateral attachments constitute the aponeurotic part of the pubo-prostatic 
or pubo-vesical ligaments ; the posterior margins, which are stretched above 
the fasciculi of urethral muscles proceeding from the ischium, have a cord-like 
form thus given to them, resembling the corners of a square tent, and pass into 
the back part of the capsule, which has been already described. It is this pos- 
terior stretching of the capsule which Muller has figured so well, and termed 
ligamentum ischio-prostaticum, and which Santesson has followed further for- 
wards, and prefers to term ligamentum pubo-ischiadicum prostatas. Denon- 
villiers calls this side part " aponeurose laterale de la prostate, or pubio-rec- 
tale." Above, the wall of the capsule is only in contact with a small portion 
of the prostate, and as it descends from the bladder and prostate to the nearest 
surface of the os pubis, it is stretched by the muscular cords from the muscular 
coat of the bladder, constituting what have long been known as the pubic 
attachments of the detrusor urinas muscle. The tense cord-like borders thus 
formed are the so-called pubo-vesical ligaments which have already been alluded 
xo. Between these the capsule forms a deep groove, and here also covers the 
venous plexus prostaticus impar, which lies above the urethra and prostate, and 
behind the symphysis pubis. The front wall of the capsule is formed by the 
triangular ligament of Colles. 

Thus, then, both the prostate and muscular part of the urethra are con- 
tained in a capsule or theca, with four sides, and as many edges, with a broad 
basis of considerable extent, firmly attached to the outlet of the pelvis, and 
with a wide-spreading floor, formed of ligamentum triangulare. The two 
anterior corners of the basis (Lig. pubo-ves) lie close together ; the two posterior 
(Lig. ischio-prostatica) are widely held apart. Not only does this apparatus 
form a strong ligament-like means of attachment for the prostate, urethra, 
venous plexuses, arteries and nerves, it contains, likewise, muscular structures 
of great importance for the urethra. The muscular apparatus has, as has 
been already explained, its outer attachment along the inner side of the long 
borders of the base of the capsule ; a circumstance which has induced San- 
esson to regard the ligamenta ischio-prostatica, as the "tendines constric- 
toris urethras." 

1850.] Anatomy and Physiology. 163 

If we inquire how this important and curious structure has so long escaped 
the observation of anatomists, we find that the reason has been that the ordi- 
nary mode of describing fasciae has made us acquainted with parts, without 
throwing any light upon their anatomy as a whole. Thus the upper side of 
the capsule is called lig. pubo-vesicalia ; its front or floor lig. triangulare ; its 
lateral surfaces, folds of the pelvic fascia, passing between the levatores ani 
and prostate ; while its back part has received the name of fascia recto-vesicalis. 
— Monthly Journal of Medical Science, March, 1850, from Mailer's Archiv., 
1849, vii. 

2. On the Existence of two new hinds of Anatomical Elements in the Medullary 
Canals of Bones. By M. Ch. Robin. — In all bones, whether short, flat, or 
long, the medullary tissue contains, besides the adipose cells, the vessels, and 
the finely granular amorphous matter, a peculiar kind of cells, which may be 
termed medullary cells; these are spherical, or slightly polyheclric, transparent, 
with defined borders,* and generally include a spherical, regular, transparent, 
sharply-defined nucleus. Between the nucleus and the cell-wall, and especially 
around the former, there exists a variable quantity of molecular granules. 
These cells are more abundant in young subjects than in adults, and towards 
the end of the period of gestation they occupy nearly the whole of the medul- 
lary cavity, to the exclusion of the adipose cells. 

Another kind of cell is met with in long and short bones, but normally in less 
amount : the knowledge of these cells, however, is important, because it is in an 
unusual development of them that some diseases of bones originate. Certain 
tumours of bone, considered by pathologists as cancerous, are not truly so, but 
are made up of large plates or flattened lamellae, sometimes polygonal, some- 
times irregularly circular, having a diameter of at least from l-20th to l-12th 
of a millimetre (or from 2 to 3-1000ths of an inch), finely granular in their 
texture, and containing from six to ten large oval nuclei, which are embedded 
in the thickness of the plates. The author states that he has met with these 
bodies as the principal components of several osseous tumours ; and that such 
tumours owe their origin to an unusual local development of a normal element 
of bone. For these peculiar bodies are found in the medullary tissue of even 
healthy bone ; being much less numerous, however, than either the true medul- 
lary or the adipose cells ; but being, like the preceding, more abundant in the 
bones of young subjects than in those of adults. — British and Foreign Medico- 
Chirurgical Revieio, April, 1850, from Gazette Medicate de Paris, December 22, 

3. Researches on the Physiology of the Medidla Oblongata. By M. Brown- 
Sequard. — The following are the results of the author's experimental inquiries, 
made upon fifty-four species of animals, belonging to the five classes of 
Vertebrata: — 1. The life of Batrachia does not seem to be considerably short- 
ened after the removal of the medulla oblongata alone, or with the rest of the 
encephalon, so long as the animals remain in air of a temperature below 46° 
(Fahr.) Many individuals have lived, in these conditions, more than three 
months. 2. The sanguiferous and lymphatic circulation, the cutaneous respi- 
ration, the digestion, the mucous, epidermic, and urinary secretions, the nutri- 
tive operations, the reflex power, and the properties of nerves and muscles, 
continue in Batrachia, deprived of the medulla oblongata, with as much rapidity 
and energy as in those which remain uninjured, and which are exposed to the 
same temperature. 3. All animals, even adult Mammalia, may survive the 
removal of the medulla oblongata during from ten to twenty minutes, when 
their temperature has been reduced below from 86° to 92°. For this result, 
pulmonary insufflation is not requisite. 4. The most remarkable differences 
present themselves in the duration of life, in the different individuals of the 
same species, after the removal of the medulla oblongata, these being in exact 
accordance with the temperature. Thus the duration of life in the Batrachia 
may be reckoned by months, between the temperatures of 32° and 46° ; by weeks, 
between 41° and 54° ; by days, between 50° and 61° ; by hours, between 66° and 
77°; and by minutes, between 86° and 104°.— Gazette Mtdicale, Dec. 22, 1849. 

164 Progress of the Medical Sciences. [July 

[These experiments, like those formerly made by Dr. W. F. Edwards, fully 
bear out the general principle, that when an animal has sustained a fatal lesion, 
the length of its survival is inversely as the rate at which it is living, and that 
this rate is directly as the temperature of its body. Thi3 temperature, in cold- 
blooded animals, is that of the surrounding medium ; whilst in the warm- 
blooded, it is maintained at a nearly fixed standard by their independent 
calorifying power.] — British and Foreign Medico- Chirurgical Review, April, 

4. On the Emission of Urine, as observed in an individual suffering from Ecto- 
pia of the Bladder. By Dr. Parmeggiani. — A man, set. 30, having entered the 
hospital at Reggio with ectopia of the posterior wall of the bladder, so as to 
exhibit the orifices of the ureters very plainly, the opportunity was taken to 
make some observations upon the mode in which the urine entered the bladder. 
The statement of physiologists that it passes in, drop by drop, was not found 
to hold good. On the contrary, from time to time, it issued in true jets, some- 
times fifteen seconds, sometimes thirty seconds, or even two or three minutes 
elapsing between these, the time varying according to that which had elapsed 
since fluids were taken into the stomach. The flow had no dependence upon 
the circulatory or respiratory movements. When emitted, the urine was fetid 
and alkaline ; but in the act of flowing furnished an acid reaction — which is 
confirmatory of the statement of Stehberger, that the urine is secreted alkaline 
and becomes acid in the bladder. 

Signs of the presence of iodide of potassium were found in one experiment 
six minutes, and in another twelve, after it had been swallowed ; these increas- 
ing during twenty-four hours, and then diminishing until they disappeared. — 
British and Foreign Medico- Chirurgical Review, April, 1850, from Omedei Annali 
vol. cxxiv. 

5. Experimental Researches on the Contractility of the Spleen. — The discovery 
of M. Kolliker, that the spleen contains a number of elongated cells, resembling 
those which are found in contractile tissues, and probably to be considered as 
a rudimentary condition of muscular fibre, has suggested experimental re- 
searches with a view to the determination whether or not the trabecular tissue 
of that organ can be excited to contraction by the electric stimulus. Such 
experiments have been performed by Professor Wagner and M. CI. Bernard, 
with positive results ; the form and dimensions of the spleen being considerably 
changed by the transmission of the electro-magnetic current through its sub- 
stance. — British and Foreign Medico- Chirurgical Review, April, 1850, from Ga- 
zette Medicate, December 22, 1849. 

6. On the Means of measuring degrees of Anaesthesia and Hyperesthesia. By 
M. Brown-Sequard. — The means proposed consist simply of an application to 
the pathological conditions in question, of Professor Weber's well-known 
method of measuring the relative discriminating power of different parts of the 
cutaneous surface, by the degree in which the two blunted points of a pair of 
compasses require to be separated from each other, in order that the double 
impression may be felt. Thus, in one case of complete anaesthesia of the lower 
extremities, the patient only felt a single impression on one leg, when the points 
of the compasses were 10, 15, or even 20 centimetres apart ; whilst on the other 
leg he could distinguish them at a distance of 12 centimetres. The normal 
limit is generally from 3 to 5 centimetres. In another case of slighter anassthe- 
sia, the limit of the discriminating power was at from 9 to 15 centimetres. 
And in another case of very slight anaesthesia, the limit was from 6 to 7 cen- 
timetres : in a case of hyperesthesia, on the other hand, which accompanied 
paralysis of the motor power, the patient could perceive the distinctness of the 
two points on the foot, when they were separated to the distance of only 5 mil- 
limetres ; the normal limit of discriminating power in that part being from 25 
to 30 millimetres. The sensibility to pain, in this case, was as much exagge- 
rated as the tactile sensibility. — Brit, and For. Med.-Chirurg. Rev., April, 1850, 
from Gaz. M6d. de Paris, Feb. 2, 1850. 

1850.] Materia Medica and Pharmacy. 165 


7. On the Cod-liver Oils of Commerce — and on the Beneficial Effects of the 
cheaper Fish Oils. — At the meeting of the Surgical Society of Ireland, Feb. 23d, 
Dr. Bagot drew attention to some of the oils sold as cod-liver oil, many such 
being found in commerce, which Dr. B. believes do not contain a drop of the 
oleum jecoris aselli. Dr. B. was induced to bring this subject before the society 
from a feeling that much credit is given to cod-liver oil for effects which may be 
equally well produced by some of the cheaper oils, and this becomes a matter 
of much importance to hospital and dispensary physicians, whose practice in 
this remedy must be much limited from the high price of the genuine article. 
" The wonderful powers of this extraordinary medicine are now so well known," 
Dr. B. observed, " that I will not dwell on them, but may be excused from 
referring to the very instructive and scientific paper with which my friend Dr. 
Benson favoured the society a short time since [see preceding number of this 
journal, p. 485], in which the curious fact was for the first time laid before the 
profession, that as the patient under the use of this oil becomes fat, just in the 
same ratio does his vital capacity decrease. His paper was of that deep prac- 
tical importance which ever characterizes his communications, and I trust the 
learned gentleman will continue his researches relative to this interesting fact, 
keeping in mind the inquiry in how far, or whether, this might be remedied by 
the continued use of tartar emetic. 

" Allow me to call your attention to the oils on the table; I have been kindly 
supplied with those two specimens of pure cod-liver oil by the Apothecaries' 
Hall, and Messrs. Bewley and Evans. I brought them that the society might 
have an opportunity of contrasting them with the other oils which may be, or are, 
sold as cod-liver oil. The specimen marked ' Cod Oil' was purchased in Lon- 
don under the name of cod-liver oil, but from the price paid for the article, it 
is impossible that it can be genuine. However, it produces the effect required 
by the physician — viz., fattening and strengthening his patient, and it matters 
little under what name it be administered, if it have a beneficial action. On 
carefully comparing it with this specimen of genuine ' Train Oil/ purchased 
at Boileaus', they seem to be identical in taste and smell, and what is remarkable, 
both give a violet colour with sulphuric acid, which many suppose to be a test 
for cod-liver oil. I am inclined to believe that there is much of this train oil 
sold, at a high price, labelled ' Oleum Jecoris Aselli / that the effects are 
equally wonderful, I have already proved to my own satisfaction, and any 
medical man may demonstrate the same by administering it to his patients. 

" To illustrate the benefit to be derived from this cheap oil, I will, from among 
many, mention one case. Mr. W., a clerk in the employment of a wine mer- 
chant, became affected with phthisis. When I first saw him, in August, 1849, 
he had disease of the apex of the left lung, which had run into abscess of con- 
siderable size. He was much reduced in flesh and strength, having profuse 
perspirations, occasional diarrhoea, harassing cough, &c. &c. He commenced 
by taking small quantities of this ' cod oil/ gradually increasing the close to 
half an ounce three times a-day. The following table will show his increase 
in weight up to the present date : — 

August 31, 1849, he weighed 

September 18, . . . .. . 8st. 6 lbs. 

October 18, ..... 8st. 12 lbs. 

November 18, ..... 9st. 1 lb. 

December 18, ..... 8st. 11 lbs. 

January 18, 1850, ..... 9st. lb. 

February 18, ..... 9st. 1 lb. 

" The first administration of the oil was attended with a restoration of appe- 
tite and general amelioration of his symptoms almost marvellous. This case 
will serve to exemplify the beneficial effects of this oil, which can be purchased 
at the low price of 3s. per gallon. This young man was able to resume busi- 
ness a very short time subsequent to his commencing the oil. I have another 

8st. 4 lbs. 

166 Progress of the Medical Sciences. [July- 

case of a young lady with diseased lung, who has been taking it since the 12th 
of February, 1849, on whom it has had the same extraordinary effect. She is fat 
and strong, able to walk eight or ten miles, although a year since she was con- 
fined to bed for a fortnight from the debility of phthisis. She was seen at that 
time by Sir Henry Marsh, who agreed with me as to the existence of disease 
of her lung. 

" One word as to the best mode of administering cod-liver oil. I consider the 
infusion of cloves to be by far the best vehicle ; for besides being a stomachic, 
and acting as a gentle stimulant, it so disguises the smell and taste of the 
medicine that it is quite possible to give it to a squeamish patient, without in- 
forming him of what the dose is composed ; and that sometimes becomes a 
matter of importance, especially with ladies who have delicate stomachs. It 
should also at first be given in small doses, half an hour before the patient 
rises in the morning, and after he goes to bed at night. 

" I trust this communication may help to clear up the question which has been 
started — viz., whether other fish oils may not have the same beneficial effect as 
the cod-liver oil? From the cases which have come under my notice, I feel 
quite certain that they are equally useful in the treatment of phthisis, and if 
this prove to be true, I need not tell the society how invaluable will be the dis- 
covery to those in poor circumstances. 

" I have also laid on the table specimens of sperm and whale oils, to show that 
they could not be substituted for cod-liver oil, both from their smell and taste. 

" Neither do they afford the violet colour with sulphuric acid. Whether these 
oils, procured from the mammalia, have the same fattening powers which the 
fish oils possess, I believe has not been yet ascertained." 

Dr. Stapleton was of opinion that whenever pure cod-liver oil could be had, 
they ought to use it, and for this reason — namely, that the liver of the cod had 
been found peculiarly efficacious in the treatment of rheumatic affections 
amongst the Norwegian fishermen. It was tolerably well known that in Nor- 
way it was not used as oil alone, but was taken in the liver itself. The latter 
was extracted from the fish, was put into the stomach which was removed from 
the cod for the purpose, and some salt and pepper being added, the stomach 
was filled up with water, and tied at one end. The whole was then boiled, and 
the liver thus prepared being used as an article of diet, was found highly bene- 
ficial in the treatment of rheumatism. But there was another point bearing 
on this important subject which deserved their attention. It was, that there 
was only one period of the season at which the liver of the cod yielded the oil 
in a state of purity — namely, just in the beginning of the season when the 
liver was of a light cream colour. As the season drew towards its close, the 
liver gradually acquired a reddish hue, and when such was the case, scarcely 
any oil could be obtained, even from a large number of them ; but in the com- 
mencement, it contained an abundance of oil of a superior quality. In the 
beginning of the season it was obtained by " cold expression," but towards the 
close, it could only be procured by boiling the livers, in which case, the product 
was exceedingly thick, had a most disagreeable odour, and would not sit so 
easily upon the stomach as the oil procured by cold expression in the early part 
of the season. He did not deem it necessary to go further into the history of 
cod-liver oil, but he might mention that an oil much superior to that obtained 
from the common cod was procured from the liver of another gadus — namely, 
the Torsk, and which was pretty extensively employed in rheumatism, and was 
thought to act more beneficially in that disease than the genuine cod oil. — Dublin 
Medical Press, March 6th, 1850. 

8. Almond Oil as a substitute for Cod-Liver Oil. — Dr. P. M. Duncan, Physi- 
cian to the Essex and Colchester Hospital, and Mr. R. S. Nunn, Surgeon to the 
same institution, have communicated to the Provincial Medical and Surgical 
Journal for March 20, the following remarks on the applicability of the common 
sweet almond oil to all cases for which cod-liver oil is prescribed. 

" In a flat and damp agricultural district, where, amongst a certain class, 
intermarriage is very frequent ; where intermittent fevers, scrofula, and all kinds 
of disease characterized by the presence of an adventitious product in the system, 

1850.] Materia Medica and Pharmacy. 167 

are very common, and where, on account of scanty food and clothing, diseases 
are generally of an adynamic type, it is not to be wondered at that medicines 
which enhance the nutritive powers should be very largely prescribed. 

" We have always subscribed to that opinion which denies the specific agency 
of the oleum jecoris aselli in tuberculous and like diseases, and attributes the 
benefit conferred to its influence on the assimilative processes. We have pre- 
scribed the cod-liver oil with great success, both in hospital and in general prac- 
tice, and consider that its only drawbacks are its nauseous flavor and high price. 
In June last, we agreed to prescribe a vegetable oil instead of the oleum jecoris ; 
and our experience is highly favorable to the therapeutical virtues of the oleum 
amygdalse. We have reason to declare that the almond oil and the cod-liver 
oil act precisely in the same manner ; and the first mentioned oil has anything 
but a disagreeable taste, and can be obtained for at least one-third of the price 
of the best cod-liver oil. Our experience of the beneficial effects of almond oil 
has been derived from upwards of two hundred and fifty well-observed cases ; 
in no one case has it purged, and the contrary effect is very frequently produced. 
We are in the habit of prescribing the oil without any adjunct, at first in one- 
drachm doses, half an hour after every meal. The dose is gradually increased. 
A drop of eau-de-cologne, or of some essential oil, renders the ' neat' oil any- 
thing but disagreeable to the taste. It is an excellent vehicle for the exhibition 
of iodine in small doses, the latter being rubbed down with a small quantity of 
olive oil, and then added to a larger amount of almond oil. The following for- 
mula has been of great use in several cases of syphilitic diseases of the bones 
and skin, in broken-down constitutions, in chronic pleurisy, and in many cases 
of chronic enlargement of the glands of the neck: — R. Olei amygdalse ^ss ; 
olei olivae gij; iodinii gr. \. M. A third part to be taken three times a day. 

" The influence of half an ounce of this oil of almonds, taken daily, upon 
the weight of some patients progressing in health under its exhibition, is very 
remarkable. In one case, there was a weekly increase of two pounds, and in 
another, of four pounds. Care must be taken to attend to the biliary secretion 
during the exhibition of the oil, which is contraindicated when there are evi- 
dences of local congestion, or of inflammation.' 7 

9. Citrate of Iron and Magnesia. — The citrate of iron and magnesia appears, 
to M. Van der Corput, likely to come into general use among ferruginous pre- 
parations, being easy of administration, and not liable to produce constipation. 
It is prepared by dissolving two parts, by weight, of recently precipitated hy- 
drated oxide of iron in a solution of three parts of citric acid ; the liquor is 
then saturated with carbonate of magnesia, and evaporated to dryness. The 
salt is in the form of shining brown scales : the taste is sweetish, very slightly 
inky, and not at all disagreeable. It is perfectly soluble in water : it is not 
deliquescent, so that it may be given in the form of powder. It may be pre- 
scribed in doses of 15, 30, or 60 centigrammes (2-g-, 5, or 10 grains). 

Syrup of Citrate of Iron and Magnesia is prepared by dissolving 8 grammes 
in 15 grammes of orange-flower water, with 180 grammes of simple syrup. 
This is one of the most agreeable preparations of iron. 

Saccharine Confection of Citrate of Iron and Magnesia. 

Take of citrate of iron and magnesia 1 drachm 

Powdered sugar 7J drachms 

Powder of canella 1 drachm 

Mix, and divide into powders, each containing twelve grains. 

Lozenges of Citrate of Iron and Magnesia. 

Take of citrate of iron and magnesia J drachm 

Powdered sugar 7 \ drachms 

Saccarine confection of vanilla .... \ drachm 
Mucilage of tragacanth, a sufficient quantity. 
Mix, and divide into lozenges of twelve grains. — London Journal of Medicine, 
April, 1850, from Journal des Con7iaissanees Me'dico-Chirurgicales, March, 1850. 

168 Progress of the Medical Sciences. [July 

10. Alkali obtained from the Khaya Senegalensis (Swietenia Senegalensis) a 
cheap substitute for Quinine. — M. Caventou has obtained an alkali from the 
above-named tree, which he thus describes : It is non-crystalline, solid, opaque, 
of resinous aspect, yellow, very bitter, slightly aromatic, and easily soluble in 
water. If this salt possess the powerful anti-periodic properties of the bark 
from which it is derived, it must become a valuable article of the materia 
medica, as the price of quinine (from the alleged scarcity of the cinchona bark) 
is becoming dearer every year. According to M. Servant, the inhabitants of 
Senegal cure the worst cases of intermittent fever by a watery decoction of the 
bark of the khaya. — London Journal of Medicine, April, 1850, from Journal de 
Pharmacie et de Chimie, November, 1849. 

11. Physiological Effects of Oil of Turpentine. — Dr. Thomas Smith, in an in- 
teresting article on the Therapeutic Uses of Terebinthinate Medicines, in the 
London Journal of Medicine (April, 1850), gives the following account of the 
physiological action of turpentine. 

"Turpentine, when taken internally, exerts a peculiar action on the mucous 
surfaces, and the tissues superimposed upon them: it increases the peristaltic 
motion of the bowels, inducing purgation, and, in very large doses, hyper- 
catharsis ; it promotes the flow of urine, impregnating it with a violet odour ; 
and, if its action be specially directed to the kidneys, may produce strangury 
and bloody micturition. It determines to the skin, producing copious and free 
diaphoresis, sometimes attended with an itchy eruption. It also taints the pul- 
monary exhalation with its characteristic smell. A large dose has been taken 
internally, and failed to produce action of the bowels or kidneys ; the vapour 
of the turpentine has then been discharged through the skin and pulmonary 
organs ; this was the case with the experiment that Dr. Copland instituted upon 
himself. I once gave half an ounce to a boy of sixteen years of age, which 
occasioned no other unpleasant symptoms than an increase of the respiratory 
movements, and acceleration of the circulation, with a tendency to somnolency, 
followed by a profuse discharge from the urinary organs. The breath and per- 
spiration were tainted with a turpentine odour for upwards of a week ; the 
bowels remained inactive until he had taken eight ounces of the compound 
infusion of senna, with ten grains of calomel ; the evacuations, when passed, 
were extremely fetid, black, and slimy, but giving off no smell of turpentine. 
Hertwig injected two drachms into the veins of a horse ; trembling, reeling, 
with inclination to pass stools, and frequent micturition ensued. Fever and 
bronchitis were set up, and the animal died in nine days. Schubert found that 
two drachms, given to a clog, caused tetanus and death in three minutes. I 
once saw half a drachm administered to a young cat : the poor creature mewed 
piteously, was extremely restless for several hours, and had constant micturi- 
tion, unaccompanied with diarrhoea ; after some hours, it fell into a profound 
lethargy, from which it awoke perfectly well; its eyes remained injected for 
several days. 

" Turpentine seems peculiarly destructive to vegetable existence. Small in- 
sects are speedily destroyed by it ; indeed, no other drug appears to exert so 
fatal an influence over the majority of parasites which infest animal and vege- 
table life. 

" When taken internally, it has been detected in the various secretions of the 
human body. Todd and Johnson have met with it in the kidneys of a patient 
who died from hemorrhage ; it has also been detected in the chyle of a dog 
and horse, to which it had previously been administered, by Tiedemann and 

12. On the Relative Potency of Chloroform and Ether, and on some Dangerous 
Effects of Chloroform. By John Snow, M. D. — Chloroform is much more 
powerful than ether, and this is one reason why it is in some respects more con- 
venient. Its greater potency depends on its being more sparingly soluble in 
the blood than ether. The quantity of chloroform required to induce insensi- 
bility is less than one-tenth as much by measure, as in the case of ether. 
Viewed in this manner, it is more than ten times as strong ; but to ascertain 

1850.] Materia Medica and Pharmacy. 169 

their comparative physiological power, when inhaled in a similar manner, their 
volatility requires to be taken into account. In order to perceive the relative 
strength of these two medicines, we may suppose that the air which a patient 
breathes is saturated at 60 deg. — the ordinary temperature of a dwelling-room 
— with one or other of the vapours, and see how much air he would have to 
breathe in either case, in order to be narcotized to the third degree — the extent 
of insensibility usually required in a surgical operation. Thirty-six minims is 
about the average quantity of chloroform required to produce this degree of 
narcotism in the adult, and this would saturate 257 cubic inches of air at 60 
deg., making it expand to nearly 300 cubic inches, which would be breathed in 
twelve ordinary respirations of 25 cubic inches each. The quantity of ether 
usually required to produce the same amount of insensibility in the adult is 
about 1\ fluiddrachms ; this would saturate 440 cubic inches of air at 60 deg., 
and increase its volume to rather more than 800 cubic inches, which would 
require thirty-two ordinary respirations to breathe it. We see, therefore, that 
twelve inspirations of air charged with vapour of chloroform are equal to thirty- 
two similar inspirations of air charged with vapour of ether, at the same tem- 
perature; and that consequently chloroform is nearly three times as strong as 
ether. In actual practice, the difference in strength is generally greater than 
this, for ether abstracts much more caloric than chloroform during its evaporation, 
thereby reducing the temperature of the air passing over it, and the sponge or 
whatever contains it, and limiting its own evaporation in a greater degree. It 
follows, therefore, that the fact of accidents not occurring under the use of 
ether, could be no guarantee that they would not happen during the employ- 
ment of chloroform. 

When an animal after it has become completely insensible, is allowed to con- 
tinue breathing air charged with the vapour, the respiration shortly ceases ; but 
if the air do not contain more than about five per cent, of the vapour, the 
heart continues to pulsate for some time after the breathing has ceased, and the 
circulation is finally arrested for want of the respiration, as in all other cases 
when death takes place by apnoea. I have heard the pulsations of the heart by 
means of the stethoscope several times for one or two minutes after the breathing 
has ceased, in cats and rabbits under the influence of chloroform. During this 
interval, life is easily recalled by means of artificial respiration ; indeed, more 
than once, moving the animal, or pressing on its chest, whilst using the 
stethoscope, has apparently been the means of resuscitating it. This persist- 
ence of the heart's action, as I have elsewhere shown, does not arise from any 
incapacity of chloroform to paralyze it, but from the circumstance that the sen- 
sibility of that part of the nervous system on which the motions of respiration 
depend, is abolished by a somewhat smaller quantity of the narcotic than is 
requisite to suspend the action of the heart. When, however, an animal is 
made to breathe air containing a greater quantity of the vapour, ten per cent, 
or upwards, death takes place rapidly in from half a minute to about two 
minutes, and the respiration and circulation cease about the same time. The 
reason of this is, that there is sufficient vapour in the lungs, at the moment 
when the breathing stops, to paralyze the action of the heart as soon as it is 
absorbed and added to that already contained in the blood. Under these cir- 
cumstances, it is evident that artificial respiration can be of no avail ; and this 
is the manner in which there is every reason to believe the greater number of 
the fatal cases of inhalation of chloroform have occurred. 

Sometimes a patient begins all at once to breathe deeply during the inhala- 
tion ; and under these circumstances, if the vapour be not largely diluted, it 
will be inspired with dangerous rapidity. The first incision by the surgeon's 
knife, when the patient is unconscious, but not totally insensible, sometimes 
has the effect of causing him to draw a deep inspiration, and to hold his breath 
at the end of it, retaining the air in his lungs ; now an inspiration of this kind 
might, on a moderate computation, introduce 100 cubic inches of air; and if 
this were charged with vapour of chloroform, by passing over a handkerchief 
or sponge, it might contain ten or twelve minims ; if the air or the handker- 
chief were warm, it might, indeed, contain much more ; but this quantity added 
to that already in the circulation might cause a fatal accident. 

170 Progress of the Medical Sciences. [July 

It must be sufficiently evident from these considerations that unless some 
means were used for regulating the strength of the vapour, fatal accidents 
would be liable to occur from the employment of chloroform. Unfortunately, 
Dr. Simpson, to whom we are indebted for its introduction, recommended it to 
be used on a handkerchief, and even held it out as one of the advantages of the 
new anaesthetic, that it did not require any apparatus. This advice, coming 
from so high a quarter, could not fail to meet with numerous followers ; and to 
this circumstance many of the accidents that have occurred must, in my 
opinion, be partly attributed. — Dublin Medical Press, April 10th, 1850, from 
Edinburgh Medical and Surgical Journal. 

13. Adulteration of Muriate of Morphia. By Morson, of London. — In my 
note, published in the last number of your journal, I stated that salicine was 
the substance used in the recently detected adulterations of muriate of 
morphia. I had come to that conclusion from a hasty examination of the 
adulterated salt, relying principally on the oil of vitriol test ; but a more care- 
ful examination to which I was subsequently led by the supposition that a 
manufacturer, disposed to adulterate, would employ a less costly article than 
salicine, has convinced me I was in error, and that sugar was really the sub- 
stance employed. This correction, although unimportant in a commercial 
point of view, calls for a few remarks with reference to the detection of sugar 
under such circumstances. The perfect similarity in colour of the reaction of 
oil of vitriol on the salt containing sugar, as compared with that produced 
when salicine is present, renders this test unavailing as a means of distin- 
guishing the two substances named when mixed with the morphia salt; nor is 
it easy to detect the sugar by its taste, in the mother-liquor resulting from the 
decomposition of the salt by ammonia, as the presence of a little muriate of 
ammonia completely masks the sweet flavour. This latter salt probably also 
affects the process of fermentation in estimating the sugar in that way, for it 
was found that the alcohol obtained from a specimen of the adulterated salt 
represented a little more than half the quantity of sugar presumed to be pre- 
sent. On the other hand, the detection of salicine offers no difficulty. It is 
simply necessary to precipitate a solution of the suspected salt in four times its 
weight of water at a boiling temperature, with very slight excess of ammonia, 
to filter while hot, and to concentrate the filtrate, when the salicine will crys- 
tallize out, being sparingly soluble in cold water. The adulterated salt has been 
in the London market for more than twelve months, although its real character 
was not known, and I have ascertained that several hundred ounces of it have 
been recently sold. — Mr. Morson, of Southampton Bow, Russell Square, in Pharm. 

Here is another exposure of the chemical frauds, respecting which we have 
already had occasion to caution our readers. The preparations which are now 
the subjects of these frauds demand the most scrupulous care and accuracy, 
both in the manufacture and in the administration ; and when we consider the 
alarming and fatal consquences likely to ensue from the circulation in the trade 
of fabricated articles of this description, we think no apology is required for 
bringing the subject prominently forward. Let us consider, for a moment, the 
probable result of the adulteration of a morphia salt with fifty per cent, of 
sugar or other inert substance. The manufacturer sells his preparation at less 
than the prime cost of the genuine article : he either obliges the honest manu- 
facturer to sell at a loss, or he drives him out of the market. The wholesale 
purchaser of the fabricated salt sells it to the retail chemist, who supplies it to 
his customers. A patient finds that the desired effect is not produced, and he 
increases the dose until relief is obtained. He procures a supply at another 
shop where the preparation is genuine, and consequently double the strength ; 
he takes the same quantity, which produces an alarming effect. We have 
known many instances in which patients have been nearly poisoned in this 
way, not only with opium and its preparations, but also with prussic acid, ex- 
tract of colocynth, and other powerful medicines. — Dublin Medical Press, Feb. 
27, 1850, from Pharm. Journ. 

1850.] Medical Pathology and Therapeutics. 171 


14. On Typhoid and Typhus Fevers. An Attempt to Determine the Question 
of their Identity or Non-Identity, by an Analysis of the Symptoms, and of the Ap- 
pearances found after Death, in Sixty-six Fatal Cases of Continued Fever, observed 
at the London Fever Hospital, from January, 1847, to February, 1849. By W. 
Jenner, M.D., Professor of Pathological Anatomy in University College, 
London. — This is the title of an extremely interesting paper, which has been 
published in successive numbers of the Monthly Journal of Medical Science, 
commencing in the number for April of last year, and concluded in the number 
for April of the present year. It constitutes one of the most important contri- 
butions to the history of continued fever that has yet been made, presenting, 
as it does, the carefully recorded histories of a, very large number of cases, ad- 
mirably arranged and analyzed, by a highly competent and reliable observer. 
We hasten to lay his results before our readers, and, as the best means of doing 
so, we shall adopt the author's own recapitulation of the differences in the 
symptoms and lesions of structure analyzed in his paper. 

"Age. — Typhoid fever was limited, in the cases here considered, to persons 
under 40 years of age ; nearly one-third of the forty-three cases of typhus were 
more than 50 years of age. 

" Mode of Attach. — As a general rule, the attack of typhoid fever commenced 
more insidiously than that of typhus fever. This observation, like all others 
in this paper, applies, of course, only to fatal cases. 

"Duration. — The average duration of the fatal cases of typhoid fever was 22 
days. Of the fatal cases of typhus fever, 14 days. Half the cases of typhoid 
fever survived the 20th day of disease. Not a single case of typhus fever sur- 
vived the 20th day of disease. 

" Eruption. — The difference in the appearance of the eruption in the two 
diseases was as great as it well could be, considering that both were of a red- 
dish hue. 

" Miliary Vesicles or Sudamina. — These vesicles were present in an equal 
proportion of the cases of both diseases under 40 years of age. But in no 
cases of typhus fever, more than 40 years of age, were they detected. 

" Subsequent experience leads me to believe that miliary vesicles are rarely 
seen on individuals more than 40 years of age ; and very rarely, indeed, if ever, 
on patients more than 50 years old. I have, during the last year — i. e., since 
my attention was directed to this point — seen these bodies on no one of the many 
patients more than 50 years of age, labouring under various diseases, that 
have come under my observation. 

"Expression, Manner, Hue of Face, &c. — As the rule, in the cases of typhoid 
fever here analyzed, the expression was much less indicative of prostration, 
and more anxious, than in the cases of typhus fever. In the former disease, 
the complexion was tolerably clear, and the flush, when present, was of bright- 
ish pink colour, limited to one or both cheeks, and often distinctly circum- 
scribed. In typhus fever, on the contrary, the complexion was thick and 
muddy, the flush of the face uniform, and of a dusky red colour. 

"Headache was a constant symptom in all the cases of typhoid and typhus 
fevers ; but it disappeared by about the 10th or 12th day in the latter, and not 
till the termination of the second, or middle of the third week, in the former. 

" Delirium commenced in three only of ten cases of typhoid fever before the 
14th day ; while it began in fourteen out of fifteen cases of typhus fever before 
the 14th day. As a rule, the delirium was decidedly more active in typhoid 
than in typhus fever. 

"Somnolence. — In eight out of nine cases of typhoid fever, somnolence com- 
menced after the 14th day of disease. In seventeen out of eighteen cases of 
typhus, before the termination of the second week. 

"Coma-Vigil. — One-fifth of the cases of typhus fever experienced coma-vigil; 
not a single case of typhoid fever experienced that condition. 

" Spasmodic Movements were nearly equally frequent in the two diseases. 

172 Progress of the Medical Sciences. [July 

"Retention of Urine, and Involuntary Discharge of Urine and Stools, occurred 
with equal frequency in the two diseases ; but at a much earlier date in typhus 
than in typhoid fever. 

" Loss of Muscular Power. — Little more than a fourth of the patients attacked 
with typhoid fever kept their bed entirely before the 7th day of disease. All 
the patients affected with typhus, whose cases are here considered, took alto- 
gether to their beds before the 7th day of disease. 

"The prostration was rarely so extreme in the cases of typhoid fever as in 
those of typhus fever. Extreme prostration, when it did occur in typhoid fever, 
was not observed till from the 14th to the 30th day, while in a large majority 
of the cases of typhus fever it was marked between the 9th and 12th clay of 

" Epistaxis was present in five of fifteen cases of typhoid fever — in not one 
of twenty-three cases of typhus fever. 

" Hearing was equally and similarly affected in the two diseases. 

" Eyes. — The conjunctivae were very much more constantly and intensely 
injected in the cases of typhus than in those of typhoid fever ; the pupils were 
absolutely larger than natural in a majority of the cases of the latter disease, 
while these were abnormally contracted in a large majority of the cases of the 
former affection. 

" Tongue. — Although individual cases of the two diseases may have closely 
resembled each other in the appearance of the tongue, yet, taking the whole of 
either group of cases, this organ presented a singularly different aspect in the 
one from what it did in the other. It was much more frequently moist through- 
out the disease in typhoid than in typhus fever. When dry, it was often red, 
glazed, and fissured, in the former ; rarely so in the latter. Again, in typhoid 
fever, when the tongue was brown, its hue was much less deep — it was of a 
yellowish, instead of a blackish, brown. The small, dry tongue, with red tip 
and edges, smooth, pale brownish-yellow far, fissured — the surface seen between 
the fissures being deep red — may be considered differentially as a diagnostic 
sign of typhoid fever. One only of twenty patients affected with typhoid fever, 
but eight of forty patients labouring under typhus fever, were unable to pro- 
trude the tongue when bidden." 

" Intestinal Hemorrhage occurred in one-third of the patients affected with 
typhoid fever — in none of those suffering from typhus fever.f 

" The other abdominal symptoms and signs need no recapitulation. 

"Appetite and Thirst. — No difference in the two diseases. 

"Pulse. — The frequency of the pulse fluctuated much more, from day to day, 
in the cases of typhoid than in those of typhus fever. 

" Cough and Physical Chest Signs. — Sonorous rale was very much more fre- 
quently present in the cases of typhoid than in those of typhus fever — i. e., it 
was present in eleven out of twelve cases of the former, and in seven only of 
twenty-one cases of the latter. Dullness of the most depending part of the 
chest, from intense congesting of the lung, was observed in nine cases of typhus 
fever — in no case of typhoid fever. 

" Sloughing appeared to be nearly equally frequent in the two diseases. 

"Erysipelas occurred in seven of the twenty-three — i. e., in nearly a third of 
the cases of typhoid fever ; in two only of the forty-three cases of typhus fever 
— i. e., in less than one-twentieth of them. 

" Cadaveric Rigidity ceased much more quickly in the subjects dead from 
typhus fever than from typhoid fever. 

"Discoloration of the Walls of the Abdomen, and of the Skin covering the larger 
Veins, was much more frequently present in those dead from typhus than 
typhoid fever. 

* This clearly indicates the difference in the amount of prostration in the two 

f I may remark that in one case only of typhus fever, received into the London Fever 
Hospital during the last three years, has blood passed from the bowels. The case re- 
ferred to was that of an old man who had hemorrhoids, which occasionally bled when 
he was in health. During the time specified, notes of near two thousand cases have 
been taken. 

1850.] Medical Pathology and Therapeutics. 173 

" Emaciation had made greater progress in the typhoid than in the typhus 

" Spots. — <The spots observed during the progress of the cases of typhus fever 
continued after death; no trace of the spots visible during life could be detected 
after death from typhoid fever. 

"Head. — After typhoid fever, the pia mater and arachnoid separated from 
the convolutions with abnormal facility in one only of nine cases examined 
with reference to the point. The vessels of the pia mater were abnormally 
filled with blood in one-third of the cases, but intensely congested in one only 
of fifteen cases ; the cerebral substance was congested in one-seventh of the 
cases. After typhus fever, the pia mater and arachnoid separated with abnor- 
mal facility in nine of eleven cases of which notes on the point were made. 
The vessels of the pia mater were congested in nearly half, and intensely con- 
gested in one-fifth, of the whole of the cases ; while the cerebral substance itself 
was abnormally congested in half. 

" Hemorrhage into the Cavity of the Arachnoid, which was not found in a 
single case of typhoid fever, had occurred before death in one-eighth of the 
cases of typhus fever. 

" The amount of serosity found within the cranial cavity was decidedly 
greater after typhus than typhoid fever. 

" Pharnyx. — After typhoid fever, this organ was found ulcerated n one-third 
of the cases. After typhus fever, ulceration of the pharynx was not detected 
in a single case. 

" Lamyx. — Ulceration of the larynx was found in one of fifteen subjects dead 
from typhoid fever — in one of twenty-six from typhus fever. 

" (Esophagus. — After typhoid fever, ulcerated in one of fifteen cases in which 
it was examined. After typhus fever, the oesophagus was free from ulceration 
in all the twenty-four cases in which it was examined. 

"The epithelium separated from the oesophagus spontaneously at an earlier 
period after death from the latter than the former disease. 

" Stomach. — In none of the fifteen cases examined after death from typhoid 
fever was the mucous membrane of the stomach softened throughout its whole 
extent; in no case did softening of the cardiac extremity approach perforation. 
In four of thirty-seven cases of typhus fever, the whole mucous membrane of 
the stomach was softened; and in four others there was such extreme softening 
of the whole of the coats of the great cul-de-sac that they were perforated by 
the slightest violence. 

" Small Intestines and Mesenteric Glands. — The presence or absence of lesion 
of these organs was the ground on which the cases of t}^phoid and typhus fever 
here analyzed were divided from each other — consequently they were invaria- 
bly diseased in the one and normal in the other. 

" Large Intestines. — After death from typhoid fever, the mucous membrane 
of the large intestines was found ulcerated in rather more than a third of 
twenty cases. In no instance after death from typhus fever. 

" Peritoneum. — As peritonitis was in typhoid fever secondary to, and depend- 
ent on, the entero-mesenteric disease, it may here be excluded from considera- 

" Spleen. — This organ was enlarged in all the cases of typhoid fever — softened 
in one-third of the cases only. Before the age of 50, it was as large after typhus 
as typhoid fever ; after that age, it was decidedly smaller in the former than in 
the latter affection. After the age of 50, it was as soft in typhus as in typhoid 
fever ; before that age, it was less frequently softened. 

"Gall-Bladder. — There was ulceration of the lining membrane of the gall- 
bladder in one of fourteen cases of typhoid fever ; in none of thirty-one cases 
of typhus fever. In the latter disease, the bile was much thicker, and of a 
darker green colour than in the former.* 

* The condition of the bile, as found after death in these two diseases, is worthy of 
more careful investigation. The difference in appearance is, in a large majority of cases, 
well marked. 

No. XXXIX.— July, 1850. 12 

174 Progress of the Medical Sciences. [July 

"Liver, Pancreas, Kidneys. — These organs were more flabby in the cases of 
typhus than in those of typhoid fever. 

" Urinary Bladder. — This viscus was ulcerated in one of the cases of typhoid 
fever — in none of the cases of typhus fever. 

"Pericardium. — This cavity contained a small amount of yellowish, trans- 
parent serosity in all the cases of typhoid fever examined. The contained 
serosity was red, from transudation of a solution of heematosin, in five of 
thirt3^-one cases of typhus fever, in which the pericardium was examined before 
the termination of the fever. 

"Heart. — The muscular tissue of this organ was much more frequently and 
decidedly flabby, and its lining membrane was much more frequently and 
deeply stained of a dark red colour, in the cases of typhus fever than in those 
of typhoid fever. 

" Lungs. — Granular and non-granular lobular consolidation were very fre- 
quent in the subjects dead from typhoid fever — rare in those dead from typhus 
fever. The reverse was the fact with reference to consolidation from congestion 
of the most depending part of the lung. 

" Pleura. — Recent lymph or turbid serosity was found in six of fifteen cases 
of typhoid fever — i. e., between half and one-third, or in the proportion of 40 
per cent. The same lesions, but much less in amount, were found in two only 
of thirty-six cases of typhus fever — i. e., one-sixteenth, or in the proportion of 
5 "5 per cent. 

" The particulars here briefly recapitulated, and still more those fully detailed 
in the foregoing papers, appear to me to prove indisputably that the symptoms, 
course, duration, anatomico-pathological lesions, and the tendency to cadaveric 
changes, are different in typhoid fever to what they are in typhus fever. 

"To account for the differences in symptoms which exist in continued fever, 
with and without entero-mesenteric disease, the two following assertions have 
been put forward : — 

" 1st. That typhoid fever is merely typhus fever complicated with lesions of 
a particular organ ; and, therefore, it is to be expected that certain symptoms 
referable to, and dependent on, that lesion will be present, and so far modify 
the symptoms of the disease. If the symptoms and signs referable to the in- 
testinal disease as a cause — i. e., the condition of the tongue, the diarrhoea, 
increased resonance, and fullness of the abdomen, gurgling in the iliac fossa, 
pain and tenderness in the same region from the fluctuation of the contents of 
the bowel — were the only symptoms by which typhoid fever was separated from 
typhus fever, although the idea might cross the mind that they were two dis- 
eases, no sufficient ground for their separation would be present, unless the 
specific cause of the one was proved to be different from that of the other. 
But, putting aside the symptoms strictly referable to the abdominal lesion, the 
general symptoms of the two diseases, in the cases here analyzed, differed 
widely ; such differences having no apparent connection with the local affection, 
but being probably, like it, dependent on some common cause acting on the 
whole system simultaneously. 

" Thus the remarkable differences in the kind, not simply amount,* of the 
rash in the two diseases ; and the tendency to local inflammations, to erysipelas, 
and to ulceration, observed in the cases of typhoid fever here analyzed, cannot, 
with any show of reason, be considered to have been dependent on the disease 
of Peyer's patches — i. e., in the same way as the abdominal signs undoubtedly 
were ; and it is to be carefully borne in mind that the external, the hygienic 
conditions of either group of cases were precisely the same in all respects. 
They occupied the same wards, partook of the same diet, slept on the same 
beds, under the same amount of clothing, and had the same physicians to attend 
them, and the same nurses to wait on them. 

" Moreover, of the symptoms common to the two, the headache continued 
longer, and the delirium and somnolence came on, as we have seen, much later, 

* I have elsewhere shown that the rash and the intestinal disease cannot be con- 
sidered supplementary of each other. See Medical Times, December, 1S49, and January, 

1850.] Medical Pathology and Therapeutics. 175 

in typhoid than in typhus fever ; and the delirium, too, possessed a more active 
character. These differences, also, cannot be explained by the presence of in- 
testinal disease in the former, and its absence in the latter affection. 

" The short comparative duration of the cases of typhus fever here con- 
sidered is another remarkable point of difference, totally inexplicable by the 
hypothesis that typhoid fever is typhus fever with intestinal ulceration. Had the 
cases eventually recovered, it might have been said that the intestinal lesion pro- 
longed the disease in the cases of typhoid fever ; but that all the fatal cases of 
fever, -with a local lesion of so severe a nature as that recorded to have been 
present in the cases of typhoid fever, should have had a much longer course 
than all those other fatal cases of fever in which no organic change of structure 
could be detected after death, appears to me inexplicable, on the supposition 
that the former is simply the latter disease, with this serious lesion superadded. 
Let me repeat, by this hypothesis we are asked to imagine that death is retarded 
in fever by extensive ulceration of the small intestines, and enlargement, soft- 
ening, and even suppuration of the mesenteric glands. Surely, it behoves the 
supporters of such a statement to bring forward cogent proofs of the identity 
of the specific cause of the two affections ere they ask us to admit its truth. 

" The same mode of reasoning appears to me equally conclusive, when we 
consider the comparatively early period of the disease at which the patients 
suffering from fever lost the ability to make muscular exertion. For to suppose 
that the presence of abdominal complication in fever invariably prevented the 
extremely early supervention of debility is, a priori, still more absurd than to 
suppose such lesions to have retarded death. How, again, are we to explain, 
if we regard typhoid as typhus with abdominal complication, the differences 
observed in the ages of the patients, in their general manner ; the muddy hue 
of the skin, and uniform flush of the face, the injected conjunctivae, and con- 
tracted pupils in typhus fever ; and the comparatively clear complexion, the 
pink flush limited to the cheeks, the pale conjunctivae, and the large pupils, in 
typhoid fever ? 

" In what way, also, are we to account for the differences observed in the 
physical breath signs, on the supposition that the one is merely the other, with 
abdominal complication ? 

" Death itself, moreover, adds new proof to the non-identity of the general 
affection in the two diseases. The comparatively rapid loss of muscular rigidity, 
the discoloration of the surface, the more flabby condition of the heart, liver 
and kidneys, the extreme softening of the stomach, and the early separation of 
the epithelium, after typhus fever, are all cadaveric changes, by which death 
makes us cognizant of a condition of the system at large, which condition 
must have existed anterior to the cessation of life from that disease ; and which 
condition could not have been present in the cases of typhoid fever, or death 
would have made it manifest. 

" I need not here more than advert to the difference observed in the lesions 
which death simply enabled us to lay bare. The almost constantly congested 
brain and membranes in typhus fever ; the frequent presence of the signs of 
pre-existing serous inflammation in typhoid fever ; the difference in the nature 
of the pulmonary lesions in the two — are inexplicable on the supposition that 
the one disease is the same as the other, excepting so far as concerns the ab- 
dominal affection. 

"Thus tried by facts — i. e., by recorded symptoms and lesions — the assertion 
that typhoid fever is merely typhus fever with abdominal complication, is com- 
pletely refuted. 

"2d. But another mode of explaining the differences which exist between 
the two diseases has been given — i. e., that the differences observed depend on 
variations in the epidemic constitution. These cases afford a complete answer 
to this assertion. For a majority of the cases here analyzed of both diseases 
were observed during the same epidemic constitution. If the reader will refer 
to p. 668 of the last volume of this Journal, he will find that nineteen of the 
cases of typhus fever I have used in these papers were collected between May 
and November, 1848 ; and that thirteen of the cases of typhoid fever were col- 
lected during the same months of the same year. For such as prefer broad. 

176 Progress of the Medical Sciences. [July 

general assertions to the details of particular but more limited facts, I may 
remark, that during three years' attentive watching of nearly all the cases ad- 
mitted into the London Fever Hospital, in which time there have been epidemics 
of relapsing fever, typhus fever, and cholera — and, consequently, according to 
those whose opinions I am here examining, as many changes in epidemic con- 
stitution — I have seen no alteration in the general or particular symptoms of 
either typhus or typhoid fevers, or the lesions observed after death from either 
— i. e., from November, 1846, to November, 1849. The cases of typhoid fever — 
which disease is rarely absent for a fortnight from the wards of the hospital — 
preserved their symptoms unchanged, and presented the same lesions, whatever 
the epidemic constitution that prevailed ; the same is true of typhus fever. 
Cases of the latter disease are also rarely absent from the wards of the same 
institution. It is there common to see patients occupying beds side by side, 
and presenting respectively the well-marked characters of either disease. 

" But to return to the particular cases here analyzed. Allowing to epidemic 
constitution all the power of modifying disease claimed for it by certain writers, 
it must be granted that whatever influence this epidemic constitution exercised 
over the group of cases without intestinal lesion, it ought to have exercised 
over the group of cases with intestinal lesion, because the cases of the two 
groups were scattered indiscriminately over the space of two years only. If, I 
repeat, the two affections were really the same disease, then the same epidemic 
constitution ought to have impressed on both the same general features, im- 
planted in both the same local lesions, and given to both the same tendency to 
cadaveric changes, and this allowing for all the modifying influence which the 
accidental presence of the abdominal lesion in the one and its absence from the 
other group might have occasioned. The analysis of every symptom, and every 
lesion, shows that the two affections were not thus assimilated by the preva- 
lence of any particular epidemic constitution. But if this epidemic constitu- 
tion, by any stretch of the imagination, could be supposed to change from week 
to week, to cause the case attacked to-day to have typhus fever, the individual 
who takes the disease to-morrow to have typhoid fever, still, it could not account 
for the fact — as well established as any fact in medicine — that typhoid fever 
rarely, if ever, affects persons more than fifty years of age ; while age exerts 
little influence in determining the occurrence of typhus fever. 

" Thus, then, the assertion that typhoid fever is merely typhus fever modi- 
fied by the prevailing epidemic constitution is as irreconcilable with facts as 
that the former disease is simply the latter with abdominal complication. 

"To conclude — In the first of these papers, I proposed to examine whether 
typhoid fever and typhus fever differed from each other in the same way as 
small-pox and scarlet fever differed from each other ; and, for the purpose of 
comparison, I laid down certain grounds, as those on which we founded our 
belief in the non-identity of the two last-named diseases. Those grounds 
were : — 

" 1st. In the vast majority of cases the general symptoms differ — i. e., of 
small-pox and scarlet fever. 

" [This holds equally true with respect to the general symptoms of typhoid 
and typhus fevers.] 

"2d. The eruptions, the diagnostic characters, if present, are never identical 
— i. c, in small-pox and scarlet. 

" [The particulars detailed in the foregoing papers prove that this is as true 
of the eruptions of typhoid and typhus fever as of those of small-pox and 
scarlet fever.] 

" 3d. The anatomical character of small-pox is never seen in scarlet fever. 

" [Just in the same way, the anatomical character of typhoid fever — i. e., 
lesion of Peyer's patches and the mesenteric glands — is never seen in typhus 

"4th. Both — i. e., small-pox and scarlet fever — being contagious diseases, 
the one by no combination of individual peculiarities, atmospheric variations, 
epidemic constitutions, or hygienic conditions, can give rise to the other. 

" [In these papers, I have not attempted to determine how far this holds true 
with respect to the diseases here treated: but I have considered it in a paper 

1850.] Medical Pathology and Therapeutics. 177 

read before the Medico-Chirurgical Society of London, December, 1849,* the con- 
tents of which I may anticipate so far as to state that, to my mind, the origin 
of the two diseases from distinct specific causes is as clearly proved as that 
scarlet fever and small-pox arise from distinct specific causes.] 

" 5th. The epidemic constitution, favourable to the origin, spread, or pecu- 
liarity in form, or severity of either — i. e., small-pox and scarlet fever — has no 
influence over the other, excepting that which it exerts over disease in general. 

" [The facts detailed in these papers prove that this holds as true of typhoid 
and typhus fevers as of small-pox and scarlet fever.] 

" If, then, the above are the grounds — and, after mature deliberation, I am 
able to assign no others — for the separation of small-pox from scarlet fever, I 
think it is indisputably proved that typhoid fever and typhus fever are equally 
distinct diseases; not mere varieties of each other, but specifically distinct — 
specific distinction being shown in typhoid and typhus fevers, as in small-pox 
and scarlet fever, by the difference of their symptoms, course, duration, lesions, 
and cause. 

" Before closing these papers, I ought to observe that, with respect to some 
secondary points — e. g., the chronological relation between the laryngeal and 
pharyngeal affections — it may be considered that I have drawn general conclu- 
sions from a too limited number of facts. But a few facts, impartially observed, 
minutely recorded, and carefully analyzed, are, I believe, more likely to give cor- 
rect results than a multitude of general observations ; and moreover, I believe 
most men would be astonished, if they had in numbers all the cases of any given 
disease they had ever seen, yet concerning which they have generalized. The 
method I have adopted, however prolix it may be, however difficult to conform 
to, however tedious the details into which it leads, has this advantage, that, if 
the observer be honest and capable of noting what is before him, thinking men 
may judge of the value of his facts, the force of his reasoning, and the correct- 
ness of his conclusion ; whereas general observations, while they are totally 
incapable of proving anything, are exposed to all the fallacies of definite state- 
ments, because the one, like the other, rests ultimately on the accuracy of the 
facts observed. If the observations, on which any reasoning is founded, be 
erroneous, no cloaking of those observations, in general terms, can render the 
conclusions correct. It has been objected to definite numerical statements, that 
they mislead the reader by an appearance of accuracy, in cases where there has 
been great inaccuracy in observation. This objection appears to me to lie 
against the condition of the reader's mind, and not against the method. For 
if the reader fails to examine, 1st, the trustworthiness of the author, and 2dly, 
the legitimacy of his conclusions, the fault is, obviously, mentally his own, and 
in noways to be ascribed to the method. Because chemists have, by the im- 
perfection of their analyses, arrived at incorrect conclusions as the ultimate 
constitution of various organic bodies, we surely would not have them hence- 
forth confine themselves to the general impressions produced on their minds by 
a series of experiments or observations. The more complicated the problem to 
be solved, the more careful ought we to be that every step in its solution is made 
correctly. How complex questions, such as arise in medicine, are to be deter- 
mined mentally — i. e., without the aid of figures — by ordinary men, I am at a 
loss to conceive. Yet physicians think to solve, by mental reveries, problems 
in comparison with which the most difficult that the most renowned mental cal- 
culators ever answered were child's play ; and not only do they think to solve 
these problems, but to carry in their minds for years the complicated materials 
by which they are to be solved. 

"Who can tell what general statements are worth, without knowing on what 
evidence they rest? One man's many is another's few. Last month (Oct.), I 
saw thirty cases of fever — to me these were few ; to men with smaller oppor- 
tunities of observing that disease, they would have been many. One man's 
frequent is another's seldom." 

[* An abstract of this paper is given in the preceding No. of this Journal, p. 384.] 

178 Progress of the Medical Sciences. [July 

15. On the Treatment of Ague by a Single Dose of Quinine. — Dr. C. Pfeufer 
states he has had many opportunities of treating this disease, and was for- 
merly in the habit of prescribing from fifteen to twenty grains, in divided doses, 
in the intervals of the paroxysms. Latterly, he has given five-grain doses, until 
from forty to sixty grains were taken, and with great success. The number of 
patients having greatly increased, during the bivouacs consequent upon the 
revolutionary disturbances, the expense of so much quinine was found a serious 
consideration ; and he determined to try whether, by a different mode of ad- 
ministration, less might not suffice; and, certainly, if the results he has arrived 
at are confirmed by others, he will have conferred no ordinary boon upon the 
distributors of charitable medical relief. He finds, indeed, not only that the 
expense may be vastly diminished, but the cure expedited and rendered more 
certain, by administering a single ten-grain dose (made into four pills, with ext. 
of millefolium), on a day free of fever. This dose is well borne, none of the 
inconveniences which result from the long-continued use of small doses, or the 
tinnitus, giddiness, &c, produced by very large ones, presenting themselves. 
The subsequent attack is weaker, and its successors still more so, the con- 
valescent remaining in the hospital from four to eight days. A tabular view 
of the particulars of thirty-four cases so treated is given. — British and Foreign 
Medico- Chirurgical Review, April, 1850, from Henle and Pfeufer 's Zeitschrift, 
B. viii. 

16. Treatment of Phthisis. — Br. James Trumbull, Physician to the Liverpool 
Infirmary, in a highly interesting paper in the London Journal of Medicine (Feb., 
1850), makes the following observations relative to the means which have been 
thought to have some power in promoting the absorption of tubercle, and espe- 
cially respecting the efficiency of cod-liver oil. 

" Whatever," he says " may be the condition of the blood and of the capillary 
vessels, which determines the exudation or secretion of tubercular matter, there 
cannot be any doubt that debilitating causes, such as innutritious food, defi- 
cient exercise, and impure air, have a powerful influence in producing this dis- 
ease. The researches which have been made in the present day in chemistry 
and physiology have tended more and more to prove the connection between 
deranged assimilation and many diseases ; and in struma, Dr. Prout has ob- 
served that all the assimilating processes are at fault, but chiefly those which 
take place between the duodenum and the circulating system, and by which 
the chyle is converted into blood. It is also well worthy of notice, that tuber- 
cles may be produced in some of the lower animals by confining them in damp 
places, and feeding them on unwholesome food. This was done with rabbits 
by Drs. Baron and Jenner,* and by Dr. Carswell ; and it is a fact of some im- 
portance, as well in reference to the curability of tubercular diseases by ab- 
sorption as in showing the power of good alimentation, that the turbercular 
disease has been removed by feeding them afterwards on more nutritious food. 
In some kinds of insects, too, it has been found that a tubercular deposit may 
be produced by feeding them on bad food, and repeatedly plunging them in 
cold water. The same influences operate on man ; for Dr. Balyf has shown 
that mental depression and confinement cause a remarkable increase in the mor- 
tality among the inmates of prisons, and that this is chiefly produced by con- • 
sumption and scrofula. Such facts show us the importance of hygienic means 
of treatment; and, viewed in connection with the power of cod-liver oil in pro- 
moting the assimilation of the food, they prove to us forcibly the necessity of 
bringing the digestive organs into as healthy a state as possible, in order to 
effect the most perfect assimilation of light nutritious articles of diet. 

"We have already shown that inflammation and tubercular deposition are 
allied processes ; and the effect of local irritation, in producing pulmonary con- 
sumption, is exemplified in the frequency of the disease in persons whose oc- 
cupations cause them to inhale silicious or metallic particles ; and I have no 
doubt that the fact, noticed by Phillips, of consumption being most prevalent 
in towns, and scrofula less so, while the reverse occurs in the country, arises, 

* Baron on Tubercular Diseases. f Medico-Chirurg. Trans, vol. xxviii, 1845. 

1850.] Medical Pathology and Therapeutics. 179 

not as he supposes, from any difference between these diseases, but, in a great 
measure, from the inhalation of particles of dust and smoke determining the 
deposition of tubercular matter in the lungs instead of the external parts. In 
all our efforts to cause the absorption of tubercles, it must, therefore, be a mat- 
ter of primary importance to prevent irritation, and to remove inflammation or 
congestion of the lungs by the usual means — local depletion and counter-irrita- 
tion more especially. The action of all the depurating organs which purify the 
blood by removing from it the products of the worn-out tissues, should be promo- 
ted by the appropriate means ; and, with the view of preventing catarrhal irri- 
tation at the earliest period, I believe that there is no means so effectual as 
washing the whole surface with tepid or cold salt and water, followed by fric- 
tion, which excites the depurating function of the skin, fortifies it against the 
impression of cold, and acts as a general tonic. 

" The condition of the blood, as ascertained by Andral, and subsequently by 
Becquerel and Rodier, furnishes another important indication in the treatment 
of phthisis, and one which has been found practically useful. In the earliest 
stage, and perhaps in some cases also before the formation of tubercles, the 
proportion of globules is below the healthy standard : as the disease progresses, 
the quantity falls ; and in one case, Andral found the proportion as low as 72 
parts in 1000 of blood. In this respect, consumption bears a resemblance to 
chlorosis, and in the diminution of the red globules, we have, in the one dis- 
ease as well as the other, an indication for the employment of chalybeate tonics. 
I may here observe that, though we have this diminution of the red globules, 
we are seldom able to discover a loud continuous murmur in the veins of the 
neck, which is so common a sign in chlorosis. This difference I account for, 
from there being in chlorosis not simply a diminution of the red globules, but 
also an increase of the aqueous part of the blood. The veins are thus kept in 
a state of tension, which is favourable to the production of the venous 
murmur. In consumption, on the other hand, especially when the disease is 
in an active state, there is a diminution not merely of the globules, but of the 
whole quantity of blood in the system, which, with the relaxed state of the tis- 
sues arising from loss of flesh, prevent the degree of venous tension" necessary 
for the full development of this murmur. When, however, the tubercular dis- 
ease has become quiescent or has receded, I have sometimes observed the oc- 
currence of a continuous murmur in cases where it had at first been absent ; 
and this I have considered a favourable sign. 

" In the preceding part of the paper, we have endeavoured to show that there 
are three ways in which recovery from consumption ma} r take place : first, by 
the shrivelling of miliary tubercles; secondly, by the transformation of crude 
yellow tubercles into cretaceous or calcareous concretions ; thirdly, by the heal- 
ing of cavities. We have now, fourthly, to show that the results of treatment 
seem to prove that tubercles may be removed by absorption. We cannot, how- 
ever, have ocular proof of this, and hence there has been doubt as to the pos- 
sibility of the removal of tubercles in this way ; but the facts I have still to ad- 
duce will tend still further to remove any doubt on this point. 

" The remedies which, I think, have most claim to our attention as agents capa- 
ble of promoting changes in tubercular matter, are mercury, iodine, the alkalies, 
and cod-liver oil. 

" As mercury is unquestionably the most powerful remedy we possess for pro- 
moting absorption of the serous and fibrinous exudations of acute inflamma- 
tion, we would naturally expect that it should have some power in causing ab- 
sorption of tuberculous deposits ; but it would seem that in proportion as they 
recede from and lose the characters of plastic organizable -fibrin, they are less 
under the sorbefacient influence of this remedy: and in ordinary cases of con- 
sumption, not distinctly produced by acute inflammation, mercury, though oc- 
casionally useful as an alterative, to promote the biliary and other secretions, 
is injurious when given so as to act upon the constitution — producing a debili- 
tating effect, and hastening the softening of tubercles. In cases of chronic 
5meumonia, which hold an intermediate place between pneumonia and phthisis, 
[ have employed the remedy in the latter way ; and, if we had reason to be- 
lieve that miliary tubercles existed in an early stage, I think we might be jus- 

180 Progress of the Medical Sciences. [July 

tified in using this remedy, with the view of promoting the mode of transforma- 
tion described by Rokitansky. The local application of mercury is a powerful 
means of causing the absorption of indurated swellings, as, for example, of 
the joints; and, as we are now able in many cases to arrest the constitutional 
disease in consumption, it becomes us to use every means likely to assist in the 
removal of the local disease also ; and none appears likely to be of more ser- 
vice than mercurial inunction. Dr. C. J. B. Williams says that he has suc- 
cessfully treated several cases, in which the signs and symptoms left him in no 
doubt as to the existence of tuberculous peritonitis, by ointment of iodide of 
mercury to the abdomen, together with iodide of potassium internally. 

" The preparations of iodine have some resemblance to mercury in their effects, 
but, unlike this remedy, they are not of any service in acute disease, but are 
more useful in causing the absorption of tubercular deposits, especially in 
glandular structures. The syrup of the iodide of iron is the preparation I have 
most frequently used, as it combines the absorbent properties of iodine with 
the tonic power of iron, and thus fulfils the indication in reference to the dimi- 
nution of the globules of the blood. I regard it as one of the best tonics we 
can use in the early stage of the disease, and I think that I have seen the early 
symptoms of phthisis arrested by it in a few cases. It was, during last sum- 
mer, the chief means of restoring to health a young gentleman, who, in addi- 
tion to cough, and loss of flesh and strength, presented the signs of incipient 
tubercular deposit at the summit of the left lung — very slight dulness, with 
some sibilant rhonchus. I prescribed it with very good effect in the case of a 
lady about thirty years of age, who came from some distance in the country to 
consult me, in July, 1847. She had become thin and very liable to colds, and 
had some mucous expectoration. She had also had an attack of spitting of 
blood three years previous. Some consolidation at the upper part of the right 
lung was indicated by slight but distinct dulness on percussion close to the 
sternum, and increased loudness of the cough and voice in the same spot ; but 
there were no mucous or other rhonchi. She wished to remove to the South of 
England ; but as the disease did not seem in an active state, I recommended hygie- 
nic means of treatment, to improve the general health. I also ordered syrup 
of the iodide of iron, with tincture of hyoscyamus in infusion of calumba, and 
inunction of iodide of lead ointment below the right clavicle. When I again 
saw her, live or six weeks after, I found her improved in health ; and the signs 
of consolidation appeared, both to her ordinary medical man and myself, to 
have diminished considerably. She has since then enjoyed pretty good health, 
and has had two children, but during last pregnancy there was some return of 
haemoptysis. After this she took cod-liver oil for a considerable time, with 
benefit. The iodide of lead ointment I have used in other cases besides this, 
with the view of causing absorption of tubercular deposits in the lungs, on the 
same principle on which we use it in scrofulous glandular swellings. I think 
it better suited to produce such an effect than the application of a concentrated 
tincture of iodine, which is a powerful counter-irritant, and as such has been 
found ' remarkably beneficial' at the Hospital for Consumption. 

" Before the introduction of iodine, the alkalis were regarded as remedies of 
considerable absorpent power. Liquor potassse is a powerful alterative medi- 
cine, and it has sometimes been found to cause absorption of an enlarged gland 
even after iodine has failed. Dr. Campbell recommended it very strongly in 
phthisis ; and Sir J. Clark has observed that the alkalis increase the urinary, 
and appear to promote the bilious secretion, and to render that of the mucous 
membranes more fluid : in whatever way they operate, they are certainly bene- 
ficial in many tuberculous affections.* Their power of promoting absorption 
of lymph and other exudation products of inflammation of the lungs or pleura, 
especially when combined with iodine, is a fact of acknowledged practical value. 
Dr. Golding Birdf has communicated some most interesting and useful informa- 
tion as to the action of alkaline remedies; he calls them depurating or chemi- 
cal diuretics, and has shown that, unlike most diuretics, they increase not only 
the fluid, but also the solid parts of the urine. This they do by a chemical ac- 

* Treatise on Pulmonary Consumption. 

f Lectures on the Influence of Researches in Organic Chemistry on Therapeutics. 

1850.] Medical Pathology and Therapeutics. 181 

tion on the exhausted and worn-out tissues ; and he thinks that parts of low vi- 
tality, such as tubercle, will be most readily acted on by these chemical agents. 
It is also worthy of notice, that the caustic alkalis are the most powerful sol- 
vents of tubercle ; and it is therefore reasonable to suppose that they will re- 
tain a portion of that power, when circulating with the blood in the capillaries. 

"Cod-liver oil has been known as a remedy for consumption and scrofula in 
Germany and the north of Europe for a considerable period, and Dr. Hughes 
Bennett* has the merit of having brought it into notice in this country. Of 
the three kinds of oil, the pale, the light brown, and the brown, it has been 
thought in Germany that the darkest coloured is the most useful; and this opin- 
ion was supported by Dr. Bennett, and is still maintained by Dr. De Jongh. It 
seems, however, to be now sufficiently well ascertained that the brown has no 
superiority over the pale oil. I have seen the best effects speedily produced by 
the purest specimens of pale oil. Dr. Williams used the pale oil prepared ac- 
cording to Donovan's method : and in the report of the Hospital for Consump- 
tion, it is stated that ' different qualities of oil have been tried without exhibit- 
ing any marked difference in the remedial effects ; but the offensiveness of some 
of the darker kinds renders their general use impracticable.' 

" The power of this remedy in controlling the progress of phthisis in a large 
proportion of cases, and even of arresting its progress in not a few, has now 
been completely established ; and the Hospital for Consumption has even fur- 
nished us with statistical facts as to the results of treatment in each stage of 
the disease. 

" In Dr. Bennett's work, we are furnished with three cases, fully detailed, of 
decided consumption, where recovery took place under the use of this remedy. 
In the appendix to the last edition, he says : ' I have succeeded, in several 
cases, in ascertaining that the caverns have completely healed up, every symp- 
tom and physical sign indicating their presence has disappeared, and there has 
remained only slight dulness on percussion, and increased vocal resonance, as 
a proof of the puckering and induration of the pulmonary parenchyma attend- 
ant on the cicatrix.' In proof of this statement, he relates two other cases. The 
most favourable account that has yet sbeen given of the efficacy of cod-liver 
oil is that published in this Journal, by Dr. C. J. B. "Williams, who states that 
of 234 cases of which he kept a record, there were no fewer than 206 in which 
its use was followed by marked and unequivocal improvement. The most nu- 
merous examples of decided and lasting improvement occurred in those cases 
in the second stage, where the tubercular matter was beginning to soften. He 
has given a full account of eleven cases in the third stage, the results of which 
may be stated as follows : In one case, a cavity seemed to have healed com- 
pletely ; in five, all the symptoms were removed and recovery took place, but 
dry cavities remained in the lungs ; in one, it seemed probable that the restora- 
tion was even more complete ; in one case, that of a child, recovery took place, 
but the existence of phthisis was somewhat doubtful ; in one, the advance of the 
disease was stayed ; in one, the patient recovered so far as to marry, but re- 
lapsed ; and in one, after temporary recovery, the patient died. 

" From the report of the Hospital for Consumption, it appears, that this reme- 
dy has been productive of more good in the treatment of phthisis than any 
agent yet employed; and the results furnished by a table of 542 cases in which 
it was given, are highly interesting. The collective results in all the stages 
show, that in 63 per cent, the symptoms improved ; in 18 per cent, the disease 
was arrested ; and in 19 per cent, only it went on unchecked. The report ob- 
serves that when it is recollected that of the whole number treated at the Hospi- 
tal, the disease was arrested in only 5 per cent., the value of this remedy, under 
which the disease was arrested in 18 per cent., must be considered very great. 
Dr. Williams speaks most favourably of the oil in the second and third stages, 
observing that, though not less satisfactory in the first than in these, it is slower 
in its action. This report, however, establishes the fact which we might natu- 
rally expect — that the greatest number of cases are arrested in the first stage. 
In nearly 18 per cent, of the males, and in 28 of the females, in the first stage, 

* Treatise on the Oleum Jecoris Aselli. 1841. 

182 Progress of the Medical Sciences. [July 

the disease was arrested ; that is, in 293 cases of "both sexes, it was arrested in 
23 per cent. It was arrested in 14 per cent, of the cases of both sexes in the 
second and third stages. 

" What I have seen in my own practice fully confirms these statements ; and 
in two of the cases which follow, u. and in. the symptoms and physical signs 
showed as hopeless a condition as in any cases of consumption I have ever 
seen, and indicated a speedily fatal termination, which, I am persuaded, nothing 
that we are yet acquainted with, except this remedy, could have averted. 

" Cod-liver oil has been called a tonic remedy, which it undoubtedly is ; but 
it differs from other tonics, and indeed from most other remedies we are in the 
habit of giving in this disease, in one important respect — that we may use it 
with advantage in every stage, and that there is scarcely any symptom which 
contra-indicates its employment. In general, the appetite speedily improves, 
the cough abates, the hectic fever diminishes, and the perspirations are arrested. 
The patient at the same time improves in colour, and gains strength and flesh. 
There are very few cases in which the pale oil cannot be taken ; and if we begin 
with a tea or dessertspoonful, and gradually increase it to an ounce thrice 
a-day, on the surface of peppermint, water, or milk, there are few persons who 
do not take it with facility, and become reconciled to it. When it causes nau- 
sea, naphtha or hydrocyanic acid will usually remove this symptom. We must 
not, however, trust exclusively to this remedy, but must give due attention to 
those general indications for treatment which have been pointed out. We should 
also remove any urgent symptoms, such as cough, by a sedative ; and morphia 
is one of the best, given either in simple oxymel, or oxymel scillse, where an 
expectorant is required. Local inflammatory action must also be removed by 
the usual means. Unless we are thus careful in removing prominent symp- 
toms, and in bringing the digestive organs into a healthy state, so that the oil 
may be assimilated, we may fail in deriving from the remedy the benefit which 
it is capable of producing under judicious management." 

17. Cicatrices in thelAings. — Dr. W. T. Gairdner produced at the meeting of 
the Medico-Chirurgical Society of Edinburgh, March 20th, 1850, a number of 
specimens and drawings, illustrative of the effects of tubercular softening, 
ulceration, pulmonary apoplexy, and gangrene in the lungs. When cure fol- 
lowed any of these lesions, the appearances found after death were so nearly 
identical, that, from simple inspection of the parts, it was often impossible to 
draw any just conclusion as to the nature of the disease under which the sub- 
ject had originally laboured. Dr W. G. expressed his belief that some speci- 
mens, generally regarded as illustrative of bronchial dilatation, were, in fact, 
examples of cavities resulting from gangrene or ulceration of the lungs. 

Dr. Bennett fully agreed with Dr. Gairdner that in the lungs, as elsewhere, 
problematical appearances were often found. To solve the doubt in such cases, 
it was necessary to associate the history of the symptoms during life with the 
lesions observed on dissection. Cretaceous concretions were not exclusively 
observed in the lung after the removal of tubercle ; any deposit might become 
loaded with salts, and dry up. The position of such concretions often afforded 
some clue to their probable origin. There were, however, intermediate cases, 
in which the precise nature of the lesion could not be made out, even with the 
assistance of the microscope. — Mo7ithly Journal Med. Science, May, 1850. 

18. Clinical Remarks on Gangrene of the Lungs. By William Stokes, M.D. 
{Dublin Quarterly Journal, February, 1850.) — In this interesting paper on one 
of the most terrible and unmanageable of the diseases of the lungs, the author 
presents the following conclusions as justifiable in the present state of our know- 
ledge of the subject. 

" 1. That gangrene of the lung is met with under a variety of forms, differ- 
ing from one another not only in the duration and violence of the symptoms, 
but also in their relations to various local and constitutional diseases. 

2. That in a great proportion of the cases, the disease is attended with pu- 
trefactive action engaging the necrosed portion of the lung, and affecting its 

1850.] Medical Pathology and Therapeutics. 183 

3. That, in the progress of a case, we may observe the septic action singu- 
larly variable. It is increased by over-stimulation of the system. 

4. That we cannot explain the symptoms in many cases of this disease, 
without assuming, either that a spot of mortification, so small as to be undis- 
coverable by physical means, causes severe symptoms, and is attended with 
super-secretion ; or that a process of putrefactive secretion precedes, in many 
cases, the death of the lung. 

5. That pain of the most extreme kind may attend this disease ; and, in the 
remittent form, appear on each access of the affection with unmitigated vio- 

6. That the contact with air is not necessary for the formation of a gangren- 
ous eschar or cavity. 

7. That hemoptysis commonly attends each access of the remittent disease. 

8. That, in the earlier periods of this disease, auscultation and percussion 
often fail in detecting any signs of organic change : or, if such is discovered, 
it appears incommensurate with the gravity of the symptoms. 

9. That, in many cases, the evidences of congestion and parenchymatous 
infiltration seem to follow rather than precede the symptoms of gangrene. 

10. That dexiocardia, from diminished volume of the lung, may occur in 
gangrene of the right lung. 

11. That gangrene may attack a lung previously hepatized from ordinary 
inflammation, or in a chronic tubercular condition. 

12. That from the pre-existence of signs and symptoms of the stages of 
pneumonia, or from the early appearance of signs of excavation, we may be 
able to distinguish between fetid abscess of the lung and gangrene. 

13. That, in certain cases of chronic bronchitis, the breath and expectoration 
may become fetid, and yet no gangrene appear to have formed. 

14. That the diseases with which gangrene may be found complicated are 
divisible into general and local affections ; but that its occurrence in the class 
of general diseases, termed putrid or asthenic, is much more rare than might 
be expected. 

15. That it is rarely observed in the typhus fever of this country, even where 
the secondary bronchial affection is intense ; but that in typhoid pneumonia it 
may be occasionally observed. 

16. That it may complicate a previously existing disease of the lung, such as 
pulmonary tubercle, or an unresolved hepatization. 

17. That it may be directly induced by the pressure of a tumour on the nu- 
trient vessels and nerves of the lung, so that, in cases of cancerous or aneurismal 
tumour, the patient may die, not from the extension of the original disease, 
but from its inducing a rapid mortification of some portion of the lung. 

18. That the disease, though always of a formidable character, is not neces- 
sarily fatal/' 

19. Case of Commimicatioji between the Rectum, Bladder and left Ovary ; Cal- 
cnlus in the left Kidney ; great Enlargement of the Liver, with lateral Curvature 
of the Spine. By T. P. Heslop, M. I). — Catherine Everall, aged 37, married, 
was admitted into the General Hospital, Birmingham, on the 22d of June, 
1849, under the care of Dr. Johnstone, an extremely emaciated woman, with 
a countenance indicative of intense suffering. She had been a patient twelve 
months previously in the hospital, and found so much relief that she insisted 
upon being brought again, though it was obviously only to die. At the former 
period she complained of extreme pain in the left lumbar region, and passed 
a large quantity of purulent urine. This latter symptom appears to have 
existed for several months previously. About the time of her last admission 
the menses disappeared, and never since recurred. Many years before, two 
stones were extracted from the bladder at the Shrewsbury Hospital, of which 
I have been unable to learn more than that they were smooth, round, and of 
great beauty, insomuch that they were kept for a long time as interesting 
curiosities by the friends of the patient. When in the hospital, she appeared 
to labour under such marked symptoms referable to the bladder that Dr. John- 

184 Progress of the Medical Sciences. [July 

stone directed it to be sounded, but no calculus was detected. Up to the period 
of her present application to the hospital, she has had great difficulty in pass- 
ing urine, and endured severe pain until she succeeded. Her husband informed 
me that she averred she had passed air from the bladder for at least twelve 
months, and that it was her opinion that the air prevented the evacuation of 
its contents, and this expulsion of air always produced marked relief. She 
appears to have had the belief that the urinary and fascal passages communi- 
cated, and was never able to account for the curious odour and appearance of 
the discharges from the urethra. She told her husband that her spine began 
to yield at the age of 14, which she attributed to over-exertion in carrying her 
younger brothers and sisters. She never had children, and has never had an 
attack of jaundice. 

She suffered such extreme exhaustion from her journey (a distance of four- 
teen miles), that it was found impossible to make a very accurate examination 
of her condition. She was ordered good diet, wine and quina with sulphuric 
acid. On the evening of the 25th she had an exacerbation of pain ; the coun- 
tenance assumed the hippocratic character ; while the strength was evidently 
failing fast. The pain was exclusively confined to the left posterior lumbar 
region, and coursed down the left iliac to the hypogastric region. These por- 
tions of the abdomen were exquisitely tender to the touch. There was a clear 
sound on percussion over the last-named regions, but the lumbar region was 
perfectly dull ; here there was distinct evidence of fulness also, but somewhat 
undefined. The right half of the abdomen was tense and absolutely dull on 
percussion, extending from the ribs nearly to the crest of the ileum. The 
limits of this, the hepatic tumour, were easily definable both by touch and per- 
cussion. The wine was increased, but she sank during the night. She passed 
purulent urine up to the time of her death. 

Autopsy. — Head not examined. 

Thorax. — Nothing worthy of note was observable in the lungs and heart. The 
right pleural cavity was diminished to a remarkable degree by curvature of the 
spine, commencing at the dorsal vertebras, its greatest convexity ending at the 
base of the thorax. The lumbar portion of the spine presented curvature, to a 
less degree, to the other side. 

Abdomen. — On opening the abdomen, the liver was seen to occupy its entire 
right half, sweeping below the umbilicus to the right posterior lumbar region ; 
its posterior border deeply notched by the spine ; its inferior surface strongly 
marked by the kidney and colon. Its consistence was much firmer than natu- 
ral ; it felt almost dry, and cut like brawn, its general aspect being that of a 
waxy liver, with solid fat deposit. The left kidney was fully one-half larger 
than its natural size. On being carefully cut open, small abscesses were found 
throughout its substance ; and several ounces of pus came from the immensely 
dilated pelvis. The infundibula were loaded with calculi, accurately moulded 
to their form ; some of these reached the calyces. The head of the ureter par- 
took of the dilatation of the other renal passages, and was occupied by a cal- 
eulus as large as a walnut, so closely impacted that it was only after some 
manipulation a probe was made to pass into the pelvis of the organ. The 
ureter below this point was not dilated to a marked degree. On proceeding to 
examine the pelvic organs, a tumour about the size of an ordinary orange was 
seen occupying the position of the left ovary. The adhesions between this 
body, the rectum and bladder, were so intimate that all these organs were 
taken out together and carefully dissected. Upon opening the bladder, which 
was of moderate dimensions, considering the age and sex, a minute hole was 
noticed in the left angle of its superior fundus. The mucous membrane around 
was minutely granular and stained of a dark slate color ; a probe was found 
to pass with the greatest facility from this point into the head of the rectum, 
which strongly adhered to the upper back part of the bladder. The tumour 
mentioned was found to be the left ovary enlarged ; externally, its color was 
bright brown, its consistence obviously less than small ovarian tumours in gene- 
ral. A soft, pultaceous, half-fsecal, half-caseous-looking matter was contained 
within it, which was found to communicate with the rectum, or, more correctly, 

1850.] Medical Pathology and Therapeutics. 185 

with the lower anterior portion of the sigmoid flexure of the colon, adherent 
to the tumour. This communication was evidently out of the direct course of 
the intestinal contents, from the presence of bands and folds in the cavity of 
the gut, both below and above the opening of communication. The finger could 
be passed along the bowel without passing into the abnormal communication 
and vice versa. The recto-ovarian did not correspond exactly with the recto- 
vesical opening, the latter being a little lower in the pelvis, but all were matted 
together. The remaining abdominal and pelvic viscera were healthy. 

The morbid appearances found in the pelvis in this case are, as far as I know, 
unique. It is difficult to understand how this poor woman sustained life so long 
with such an amount of disease going on in the abdomen. Nor is it by any 
means easy to give a decided opinion as to the nature of the ovarian tumour. 
There was no evidence of tubercle or cancer, the two most common causes of 
abnormal communication between the various organs of the body. Perhaps the 
only explanation that can be oiFered is, that a slow process of inflammation 
had been for a long time silently throwing out its characteristic exudations, 
and gradually glueing together those organs lying nearest to the great perma- 
nent lesion of the left kidney, by a selection too obvious to require further 
mention ; upon the adhesion followed the ulcerative process, and so ensued the 
remarkable appearances discovered after death. It is impossible to imagine 
that the communication between the ovary and rectum could have existed long; 
for although, from the peculiar anatomical character of the former, the cavities 
of these organs did not communicate freely, and the existence of a great pus- 
discharge from a neighboring organ might have tended to check it, irritation 
must have been produced in no long time after the connection, sufficient to cause 
ovarian suppuration, with pelvic abscess. 

It will be observed that the account of the woman passing air, if not fseces, 
from the bladder, was obtained after her death from her husband. We must 
take such observations with caution, although these inquiries were made with 
scrupulous care ; and in further proof of the correctness of his answers, I may 
add that the poor woman had frequently attempted to describe her sensations 
and notions to her medical attendants, who treated them with incredulity. — 
Dublin Quarterly Journal, Feb., 1850. 

20. Granular Corpuscles in the Encephalon and Spinal Cord of Hemiplegia 
Patients. — Dr. Ludwig Tuerck has described the microscopic appearances pre- 
sented by the brain and spinal cord of three hemiplegic patients. His obser- 
vations tend to show the necessity of employing other means than the unaided 
eye, in the investigation of parts supposed to be the seat of disease. We not 
unfrequently hear of post-inortem examinations, especially of the nervous 
centres, in which no morbid appearances have been detected either by the 
eye or by feel. The state of the brain or spinal cord is also often vaguely 
described as being "somewhat hardened," "of rather firmer consistence than 
usual;" and nothing more is said about the subject. Now we have no doubt, 
that if a microscopic examination were made in such cases, we should often 
find unequivocal proofs of disease. The first and second of the cases related 
by Dr. Tiirck entirely prove the correctness of this assertion. In them, the 
spinal cord was apparently healthy, and of proper consistence; but when 
examined with the microscope, was found to be the seat of disease. 

Case I. — The first case was that of a woman aged 73, who had had paralysis 
of the left side for six months. There was an apoplectic cyst on the outer side 
of the right corpus striatum and optic thalamus, with white softening of the 
latter; and numerous granular corpuscles (kornerkorperchen) were met with as 
deep as the crus cerebri. The spinal cord appeared healthy to the naked eye ; 
but on dividing it into its lateral halves, it was found, under the microscope, 
to contain a large number of sinular bodies. The left lateral half contained a 
large number, while they were much fewer on the right side. Dr. Tiirck then 
made fine vertical sections from without inwards ; and found that the most 
superficial sections on the left side showed the granular corpuscles in great 
number, while in a similar situation on the right side they were entirely 
absent, and only began to appear singly towards the middle line. From this 

186 Progress of the Medical Sciences, [July 

examination, the interesting result was brought out that the disease in the 
cord was limited to the same side as that on which the paralysis had existed — 
the opposite side to that on which the brain was diseased. 

Case II. — The second case, was that of a man, forty years of age, who had 
laboured under paralysis of the right side for half a year. There was an apo- 
plectic cyst in a similar situation to that mentioned in the first case ; the right 
thalamus had undergone white softening as deep as the crus cerebri, and pre- 
sented an abundance of granular corpuscles. The pons Varolii, which was not 
examined in the first case, also contained them ; the medulla oblongata pre- 
sented them in abundance on the right side, but more sparingly on the left ; 
and on the left side of the spinal cord they were very abundant, while they 
were wanting on the right. From the pons downwards, all the parts were of 
normal consistence, and appeared to the naked eye to be healthy, both entire 
and in section. 

Kemarks. — Two explanations may be given of the origin of these bodies. 
They either arose from an extension of the disease from the crus cerebri down- 
wards, or they were the effect of the hemiplegia produced by disease of the 
brain, which induces a process of exudation in one-half of the spinal cord. 
As to the first of these suppositions, it is difficult to understand why the exten- 
sion of the disease should be confined to one side, and especially why it should 
not have extended to the opposite side at the point of decussation. With re- 
gard to the second explanation, it is to be observed, that in both cases there 
was a high degree of paralysis of motion, while sensation was but little 
affected: and hence, if this explanation be adopted, the exudation process 
would have to be considered as having a connection with paralysis of the motor 

In several other cases of hemiplegia, from cerebral diseases, the spinal chord 
lias been found healthy. 

Case III. — The third case is one of a woman, forty years old, who had had 
hemiplegia of the left side for a year and three-quarters. The upper extremity 
was perfectly paralysed ; the lower one less so ; sensibility appeared normal. 
There was an old apoplectic cyst in the right corpus striatum and optic thala- 
mus. Numerous granular corpuscles were observed, which rapidly decreased 
in proceeding downwards ; so that the right crus cerebri, the pons Varolii, the 
medulla oblongata, and the upper sections of the left half of the cervical por- 
tion of the chord, only presented them singly. They were much more numer- 
ous from the origin of the third to that of the seventh cervical nerves. From 
this point downwards, they again decreased, but at the lower part of the dorsal 
portion again began to increase, until they reached their maximum at the ori- 
gin of the lumbar nerves. From this point they again diminished, and at the 
origin of the lower sacral nerves they entirely disappeared. The nerves on the 
diseased side were found perfectly free from the corpuscles, even a few lines 
from their origin. The right half of the spinal cord presented them only in 
the middle line, the medulla oblongata only a very few: the left half of the 
pons, as well as the left crus cerebri, contained none. 

The fact that in this case the disease was not equally extended, the parts 
between the shoulder and hip joints as well as that between the brachial plexus 
and the encephalic cyst, showing very few of the corpuscles, tends to point out 
that the disease of the spinal cord cannot be considered as an extension of 
that which existed in the brain. — London Journal of Medicine, April, 1850, from 
Zeitsclirift der K. K. Gesellschaft der Aerzte zu Wien, January, 1850. 

21. Crypto gamic Vegetations in the interior of the Hair in Favus. — Dr. C. Wedl 
has published an account of his having discovered cryptogamic vegetations in 
the interior of the hair in favus. After briefly referring to the observations 
of Gruby, Glinsburg, Malmsten, and Lebert, he says : — 

I directed my attention to the interior of the hair, making use of a concen- 
trated alkaline solution to render it more transparent. This solution acts on 
some parts of the hair in a very remarkable manner ; in different strata of it, 
there appear small elongated gas-bubbles, with a sharp dark outline, giving the 
appearance of an interrupted canal ; sometimes also larger gas-bubbles are 

1850.] Medical Pathology and Therapeutics. 187 

seen lying at the outside of the hair. The latter gradually becomes more tran- 
sparent; and, in the situation of the dark broken canals, there appear filaments 
formed of elongated quadrangular or roundish molecules ; these extend through 
a certain portion of the hair, here and there giving off branches, and are to be 
found in all layers of the hair. T-hese filaments consist of granules arranged like 
beads. Their transverse diameter varies ; their length is also very variable ; 
here and there, only a few granules are linked together, while in other parts 
there are several dozens of them. The branches which spring from them are 
sparse, generally very short, and always single ; the direction of these filaments 
is in the longitudinal axis of the hair. I have never seen them hanging from 
the outside, unless I had torn the sheath of hair, or the whole hair, by rubbing 
it to and fro on the glass, after it had been acted on for an hour by strong 
liquid potassse. On the surface, one often indeed sometimes sees regularly 
arranged filaments surrounding the hair; but the most beautiful and conspi 
cuous are these transverse granular filaments, at the place of exit of the hair 
from the epidermis. In the latter, which often remains hanging when the hair 
is torn out, are usually some pretty numerous groups of granules (sporidia), 
and here and there a granular filament comes into view, which passes trans- 
versely across the hair, or even seems to end in it. 

I could not ascertain with precision the entrance of the filaments of the de- 
pendent epidermis into the hair; but I have no doubt that such is the case, 
because these granular filaments are most abundant at the above-mentioned 
point of exit ; moreover, they decrease as they proceed upwards, and disappear 
at the end of two or three lines ; they extend some way down, but not in such 
numbers, and do not seem to reach the bulb. The point of concentration of 
these filaments is, then, the place where the hair emerges from the epidermis ; 
it is here surrounded with the vegetations of favus. In order to establish the 
fact that the filaments in the hair are really fungous growths, it is necessary 
to examine fungi, but especially those of favus, under the action of strong liquor 
potasste. There also is an extrication of gas under the microscope ; the spori- 
dia and thallus fibres are not dissolved, but are rendered more conspicuous, 
while the epidermis cells become faint. Dr. Hebra perceived the development 
of a fetid gas in his researches, when fungi were exposed longer than usual to 
the action of liquid potassse. 

With regard to the frequency of this appearance, it is to be observed that in 
most cases of favus, it is possible to find these fungi in the hair, especially when 
light. When it is dark-coloured, it requires to be macerated about half an hour 
in strong liquor potassse ; but in light hairs, the sporidia can be seen in from 
five to ten minutes. 

This remarkable circumstance — the growth of fungi in the interior of the hair 
in favus — gives an explanation of its well-known dryness and brittleness, for 
the nutrition of the hair must be interfered with by the parasitic structures. 
Moreover, these observations throw light on the long known rule in derma- 
tology, that, in order to cure favus effectually, the hair must be removed. 
London Joum, Med. March, 1850, from Zeitschrift der K. K. Gesellschaft der 
Aerzte zu Vien. 1849. 

22. On Anemia from Diminished Proportion of Albumen in the Blood, and on 
the Dropsies which it occasions. By MM. Becquerel and Rodier. — The follow- 
ing are the conclusions appended to the memoir on the above subjects, published 
in the Gazette MMicale de Paris, No. xv., 1850. 

1. Besides the form of anemia which results from a diminution in the pro- 
portion of the blood corpuscles, we must acknowledge the existence of another 
pathological condition, characterized by the low proportion of the albumen of 
the serum. 

2. This diminution of the albumen of the serum may be rapidly produced ; 
it is then announced by paleness, by a yellowish tint in the complexion, by 
great debility, and, above all, by general anasarca, without albuminous urine. 

3. A great number of acute dropsies, which, at the present time, are regarded 
as special diseases [essentielles) , ought obviously to be attributed to this patho- 
genic cause. 

188 Progress of the Medical Sciences. [July 

4. The diminution in the albumen of the serum may also be sloioly produced ; 
it then constitutes a chronic pathological condition, which betrays itself by 
certain symptoms — the pallor and yellow tinge of the face, extreme debility, 
and, finally, general dropsy, more or less considerable, without albuminous 

5. The greater proportion of the dropsies which used to be considered essen- 
tial and passive, may be referred to the preceding section. 

6. Diminution in the amount of the albuminous constituents of the serum, 
whether produced by an acute or by a chronic process, is quite independent of 
the diminution of the amount of blood globules. These two alterations of the 
blood are, however, very frequently found to co-exist, and sometimes the one, 
sometimes the other, predominates. 

7. A diminution in the proportion of the blood globules is incapable of in- 
ducing dropsy, unless associated with diminution in the proportion of the albu- 
men of the serum. 

8. The additional symptoms which are superadded to those above mentioned, 
when diminution of the blood corpuscles complicates the case, are, a " bruit 
de souffle," with the first sound of the heart, a continuous " souffle" in the 
jugulars, or an intermitting one in the carotids, dyspnoea, and palpitations. 

9. The causes capable of determining the slow and chronic loss of the albu- 
men of the blood are insufficient alimentation, considerable losses of blood, 
long-continued diarrhoea, the influence of terrestrial miasmata, &c. 

10. The production of the same effects under the influence of organic dis- 
eases, such as heart affections, or granular disease of the kidney, constitutes a 
true cachectic condition, a cachexia. 

11. The pathological condition to which the term cachectic is generally ap- 
plied, is nothing but the assemblage of symptoms resulting from diminution of 
the albumen of the serum, united or not with some diminution in the amount 
of blood corpuscles. The first of these causes accounts satisfactorily for the 
frequency of dropsies in such cases, for the discoloration of the skin, and for 
the extreme state of weakness likewise described. The second explains the 
" bruits," cardial and vascular, the dyspnoea, palpitations, &c. 

12. The preceding distinctions exercise an important influence, and ought to 
be taken into consideration, both in diagnosis, prognosis, and in the treatment 
of dropsies. 

[MM. Becquerel and Rodier, in the preface to their essay, mention that dimi- 
nution in the albuminous constituents of the blood was first observed, in con- 
nection with Bright' s disease, by Drs. Gregory, Christison, and Bostock. The 
accuracy of their observations was confirmed by subsequent analyses by Rayer, 
Andral, and Gavarret, and the authors of the essay themselves. We cannot 
subscribe to the whole of the twelve conclusions above given. Acute general 
dropsy, without albuminous urine, disease of the heart, &c, is, in our expe- 
rience at least, a very rare affection, and there is, we think, no reason to doubt 
that organic diseases, obstructing the circulation, may induce anasarca, without 
the intervention of the cachexia from diminished albumen. But we acknow- 
ledge that, for the explanation of certain chronic oedematous conditions often 
observed in the progress of phthisis, during convalescence from typhus, from 
ague or dysentery, in chlorotic females, &c, the theory of MM. Becquerel and 
Rodier seems well adapted. We must object to the doctrine which connects 
the venous murmurs of anemia with diminution of the blood corpuscles, be- 
lieving that there is not a particle of physical evidence to justify the authors 
in adopting it. True, analysis in such cases shows a small proportion of blood 
corpuscles, but how the impoverished condition of the blood operates in pro- 
ducing the sounds is unexplained, and by chemistry, of course, inexplicable.] 
Monthly Journal of Medical Science, May, 1850. 

23. On Chlorotic Tinnitus. — From time to time, for years past, Dr. Froriep 
has met with, in delicate yet florid-looking girls, tinnitus aurium in various de- 
grees, oftentimes accompanied with a considerable difficulty of hearing. He 
long treated these cases with every variety of means, without any good results. 
Bearing in mind, then, that symptoms of apparent congestion in chlorosis are 

1850.] Medical Pathology and Therapeutics. 189 

so beneficially treated with iron, he employed it in these cases, whenever the 
general condition and the white lips and gums, in even fresh-coloured counte- 
nances, seemed to indicate a chlorotic basis in the disturbance of the health ; 
and he is very anxious to impress on practitioners the great benefit that ensued. 
No disease is more common than chlorosis, and none so often mistaken or over- 
looked in some of its forms, so that many young women lose several of the best 
years of their lives, merely because ferruginous preparations have not been ad- 
ministered for a few months. — British and Foreign Medico- Chirurgical Review, 
April, 1850, from Froriep's Notizen, Bd. x. 

24. Chemical Researches on the Nature and Cause of Cholera. By R. D. Thom- 
son, M. D., of Glasgow. (Proceedings of Royal Medical and Chirurgical Society, 
Jan. 22d, 1850.) — In the first part of the paper, the author detailed the results 
of chemical analyses of the blood, urine, and intestinal discharges, in the cold, 
or " lymphatic/' stage of cholera ; and in the " biliary/' or febrile stage. The 
main results arrived at were — 1. That in the cold stage of the disease, the spe- 
cific gravity of the blood, and of the serum separated from the clot, is increased ; 
that the proportion of water is less than in health, by at least nine per cent., 
and in some cases by as much as seventeen per cent. ; that both the organic 
and the inorganic components of the blood are proportionally increased in 
amount ; but that the increase of the insoluble salts is much greater than that 
of the soluble. 2. That the intestinal discharges, in the cold stage, when of the 
true " rice-water" character, resemble closely, in their chemical composition, 
the fluids of hydrocele and hydrocephalus ; that their flocculi are formed of 
epithelial scales, and the watery part of water, containing a small portion of 
organic matter (albumen) and salts (chloride of sodium, carbonate of soda, earthy 
phosphate, alkaline sulphate, and some lime). 3. That the small quantity of 
urine sometimes found in the bladder, in this stage, presented no apparent 
aberration from an ordinary standard. 4. That in the biliary, or febrile stage 
of cholera, the blood soon regains its normal proportion of water, or even an 
excess of it ; and that the other constituents resume their natural relation to 
each other. 5. That the urine, in the biliary stage, in several cases contained 
albumen, but presented scarcely any other deviation from the urine of health, 
except in the amount of urea, which at first was deficient. 

In the second part of the paper, the author described some experiments, in- 
stituted by him, with the view of determining whether any poison could be 
detected in the atmosphere. In one series of experiments, it was ascertained 
that no solid matter existed in the air; but ammonia was obtained from it in 
the proportion of 0'319 grains of caustic ammonia, or 0*731 grains of carbonate 
of ammonia to 1,000 pounds of air. By another series of experiments, it was 
determined that no carbon or hydrogen existed in the atmosphere, except in 
the states of carbonic acid and water ; while carbonic acid was obtained in the 
proportion of one volume to 6,650 volumes of air. 

The author inferred that the cause of cholera is not a specific tangible poison 
introduced into the body from without, but rather a vicarious transference of the 
cutaneous excretion to the intestinal mucous membrane, dependent partly on atmo- 
spheric influence, and partly on a predisposing state of the system in those who are 
affected with the disease. 

Dr. Baly said that the author's hypothesis of the cause of cholera was not 
supported by the phenomena of the disease ; for not only would the suppression 
of the cutaneous and pulmonary exhalations, and the transference of the fluids 
normally excreted by the lungs and skin to the intestinal mucous membrane, 
be inadequate to produce the enormous discharges which drain the system of 
its fluids ; but it is a fact that the cutaneous exudation is, in many of the worst 
cases of cholera, greatly increased, a watery fluid being in these cases poured 
out by the whole surface of the skin, as well as by the mucous membrane of the 
intestines. The draining away of the watery part of the blood was certainly 
the main phenomenon of the disease, all, or nearly all, the others being second- 
ary to and dependent on it. It undoubtedly was the cause of the coldness of 
the body ; but it prevented the development of animal heat ; not, he thought, 
by rendering the blood thick, and thus incapable of circulating quickly, as 
No. XXXIX.— July, 1850. 13 

190 Progress of the Medical Sciences. [July 

suggested by Dr. Snow, "but by rendering impossible those chemical changes 
which normally go on in all parts of the capillary system, and which are the 
source of the animal heat. The circulation in cholera is undoubtedly much 
retarded ; but the rapidity with which the nervous system of the patients is 
affected by chloroform, inhaled into the lungs, shows us that the motion of the 
blood would still be sufficient to allow of some evolution of caloric, if other ne- 
cessary conditions were present; but an essential condition for the normal 
processes of nutrition, and for the chemical processes on which the temperature 
of the body is dependent, seems to be the presence of a certain proportion of 
water in the blood ; and it is most probably because this is wanting, that the 
body becomes cold. To the same causes are obviously to be ascribed the arrest 
of the natural secretions of the liver and kidneys, and the depressed state of 
other organic functions of the body ; and even the remarkable condition of the 
mind, and of the sensitive and motor functions — their state of comparative in- 
tegrity — not only affords evidence that the nervous and muscular systems are, 
in a great measure, independent of the watery part of the blood, so essential 
to the organic functions, but is itself a result of the loss of that part of the cir- 
culating fluid. Under ordinary circumstances, if the respiration continued so 
imperfect, and the secretion of urine were suspended for a long period, as they 
are in the cold stage of cholera, the blood would become charged with car- 
bonic acid and urea, and coma would result. In the cold stage of cholera, the 
natural chemical processes of the body are brought nearly to a stand-still, by 
the loss of the water of the blood, and neither urea nor carbonic acid is formed 
in large quantity ; the powers of the mind and of voluntary motion are there- 
fore left comparatively unimpaired. 

Mr. "W. F. Barlow could not discover how failures to demonstrate any poison 
in the atmosphere could lead to inferences of its non-existence. Probably it 
was so subtle as to defy all scrutiny. Could the poison of small-pox or scar- 
latina be demonstrated in the atmosphere ? Yet, was there any doubt that the 
air could be made infectious by, and could communicate, those diseases ? He 
had paid some attention to the state of the muscles in cases of cholera. Nothing 
was more marked than the extreme excitability of the muscles during life, and 
their extraordinary manifestation of irritability after death. The facts which 
related to these points were most obvious ; but as to the causes of them, there 
were so many difficulties in the way of satisfactorily accounting for them, that 
he begged the few words which he had to offer might be viewed as suggestive, 
and not positive. The condition of the blood must be considered, if we would 
even approach a rational conjecture on the state of the muscles. It seemed 
pretty clear that there was a great defect in the formation of carbonic acid, in 
cases of cholera, and therefore in the production of animal heat. He had list- 
ened with interest to what had fallen from Dr. Baly respecting the failure of 
chemical changes in the blood, and their consequences. There appeared a 
broad difference between death in the collapse of cholera and death by asphyxia, 
as ordinarily considered ; in the latter, noxious blood circulated, and impaired 
the irritability ; but in the former, carbonic acid could not be carried freely 
through the system ; if it were, coma would follow, and the heart's action would 
cease, even more quickly than it was observed to do. The elevation of tempe- 
rature after death is very difficult to explain. It does not depend on the post- 
mortem muscular contractions, because extreme elevation of temperature has 
occurred when the contractions have not been met with. A formation of heat 
takes place sometimes after death ; and in cases where the body was actually 
cold at the time of decease, the temperature has risen to 109° Fahr. As a sug- 
gestion, Mr. Barlow threw out the idea that this was caused by chemical 
changes going on in the blood after death, such as occur during life. — London 
Joum. Med. March, 1850. 

25. Gooseberry Disease. — In Meiningen, a peculiar affection of the skin has 
been long known under the above name. Children seem especially liable to it ; it 
is observed during the season of the year when the gooseberries become ripe ; and 
only attacks those individuals who pluck the berries from the bushes, or are 
much in the gardens. The symptoms are intolerable itching of the skin, fol- 

1850.] Medical Pathology and Therapeutics. 191 

lowed by eruptions, commonly of the papular form, frequently vesicular or pus- 
tular. Sometimes erythematous patches or ulcerations are observed. The 
flexures of the joints, especially of the lower extremities, are the chief seats of 
the diseases ; and its severity is generally proportionate to the fairness and deli- 
cacy of the patient's skin. 

Dr. Jahn, of Meiningen, had, for several years, been familiar with this spe- 
cies of prurigo ; had observed that the eating of gooseberries had nothing to do 
with its production, but that individuals who, without even tasting of the fruit, 
were much occupied in the neighbourhood of gooseberry bushes in gardens, 
were apt to suffer. The precise connection between the bushes and the skin 
affection, he discovered in the summer of 1848. On examining the legs of a 
girl who was suffering severely from the disease, he observed a large number 
of minute yellow points round the margins of some of the sores, and, on look- 
ing at a few of these through a microscope, he found the points converted into 
great spider-like insects. Professor Emmrich, of Meiningen, recognized these 
mites as specimens of the Leptus autumnalis of Latreille. Jahn has since dis- 
covered the insect in other cases of the disease ; has ascertained that it is very 
frequently to be met with on the leaves of the gooseberry plant, and, as different 
species of the genus Leptus are known to attack the human skin, the origin of 
the gooseberry disease is no longer a mystery. Microscopic examination has 
shown that the orifices in the cuticle, leading to the glands of the skin, are like- 
wise the passages which the parasite selects for its inroads. The treatment of 
the disease is very simple. If the patient ceases for a few days to visit the 
gardens, and washes the affected parts with soap and water, or with a lotion 
containing hepar sulphuris, a cure is soon effected. 

Jahn mentions that there are certain circumstances in the topography of 
Meiningen particularly favourable to the development of the Leptus autumnalis, 
but it is highly probable that it may, in other localities, produce similar effects 
in warm moist seasons. — Monthly Journ. Med. Sci., March, 1850, from Jenaischc 
Annalen, Heft I., Band I. 

26. Cases of Abscess behind the Pharynx. By Christopher Fleming, M. D. — 
The presence of abscess behind the pharynx in childhood, and especially in 
infants, is often difficult, and the following cases are therefore of some practi- 
cal value : — 

Case I. — Francis Kelly, aged two months, was observed by his mother, a few 
days before her application to me at the Netterville Hospital,* to have a pecu- 
liar snuffle in his breathing, some difficulty in deglutition, and occasional attacks 
of dyspnoea of variable duration. In all other respects, the child was, and had 
been from birth, in excellent health. He was a well-thriven child, and his 
only nourishment was the breast. The "epidemic influenza" being then pre- 
valent amongst the children of the poor, I considered these symptoms as premo- 
nitory of an attack of it, and directed my treatment accordingly, but the child 
did not improve. On the contrary, the symptoms above noted gradually in- 
creased in intensity, and severe fever was superadded. The child from day to 
day was intolerably restless ; he could only suck for a moment or so, spasmodi- 
cally snapping the breast in his mouth, when a violent paroxysm of dyspnoea 
would force him equally abruptly to drop it. In one of these paroxysms he 
was seized with a fit of convulsions, on about the eighth day from the date of 
his illness. This occurred about the middle of last month. 

The features of the case now assumed a most alarming aspect, and a con- 
vulsive fit appeared to be momentarily threatened. The child lay in a semi- 
lethargic state, with the countenance full and bloated, and the features con- 
stantly undergoing changes from repeated muscular twitchings. The eyelids 
were half closed, and the eyeballs protruding. The tongue in perpetual 
movement, projected beyond the teeth and lips, as if too large for the mouth, 
a position which the mother remarked it retained within the last few days, 
during the casual slumbers of the child. In addition, the snuffle-breathing 

* Mr. Torney, the resident medical officer at the instituton, witnessed the progress of 
this case throughout. 

192 Progress of the Medical Sciences. [July 

was most intense, accompanied by a loud gurgling noise in the fauces, and the 
dyspnoea and dysphagia were equally urgent. All symptoms were aggravated 
by attempting to put the child to the breast. From the cries of the child, it 
was obvious the larynx was unaffected, and no physical indication of any tho- 
racic lesion could be detected. Under all these circumstances, I directed my 
attention to the pharynx ; the examination produced a most violent paroxysm 
of dyspnoea, during which the child was seized with a slight convulsive fit. I 
satisfied myself that an abscess existed there, and bringing to my recollection 
the fact I had recorded in my former communication, that a spontaneous dis- 
charge through the nose had taken place in the case of a child aged seven 
months, then reported, it occurred to me that I might, under the circumstances 
of this case, artificially imitate nature. I took my opportunity, and, rapidly 
passing my finger, pressed it with force against the abscess ; purulent matter 
darted through the anterior nares. Afterwards the child appeared to suck with 
less uneasiness, and the respiration was improved. From day to day a varia- 
ble amount of discharge took place from the nose, accompanied by very trifling 
alleviation in the prominent symptoms. The child, however, was able to take 
more nourishment, and the act of sucking was less distressing. About this 
time Mr. Colles and Mr. Wilmot saw the case, when the characteristic features 
of the abscess were still well marked. I was obliged more than once to make 
forcible pressure against it with my finger, to keep the opening free, and had 
yet doubts whether I should not make an opening through the mouth. With 
this view I consulted Sir Philip Crampton, being anxious as well for his opin- 
ion as that he should see a case of the kind in so very young a subject. In 
his examination of the fauces, so violent a fit of convulsions supervened that 
he recommended me to rest satisfied with the opening already made, as he ob- 
served the purulent discharge from the nose then present, and as, from the very 
limited capacity of the mouth of the child, and its great sensibility, risk might 
attend further interference. I acted on his suggestions, gave the child mild 
stimulants and nutriment, and enjoined that position whereby the matter could 
get free egress, as in the former case. The child is rapidly improving in health, 
and has lost all the alarming symptoms which existed. The snuffle-breathing 
has not as yet completely disappeared, but the respiration and deglutition are 
natural. The child can suck continuously, and is getting fat. 

Case II. — In July last, a young girl, aged eleven years, was brought to my 
friend, Dr. Montgomery, complaining of uneasy sensations about the throat 
and neck, which were to be dated to the latter end of the preceding April, and 
were not referable to any special cause. These sensations commenced with 
what is commonly termed a crick or stiffness in the back of the neck, and con- 
tinued with variable intensity, causing more or less uneasiness, and often ex- 
treme pain in the ears. The movements of the head and neck were extremely 
limited, and necessarily measured with great caution to render them tolerable. 
The girl was delicate-looking, of strumous aspect and strumous constitution. 
Having had enlarged tonsils, and complaining of difficulty in swallowing, Dr. 
Montgomerv's attention was early directed to the throat, where, after the lapse 
of six or eight weeks, a train of symptoms developed themselves, which led 
him to the conviction that an abscess was about forming at the back of the 
pharynx. Under these circumstances I saw the child, and I found all the 
symptoms to indicate its presence. The countenance was peculiarly expressive, 
the voice nasal and muffled, and the movements of the head and neck very re- 
markable. The latter particularly brought to my recollection similar move- 
ments attendant on disease of the cervical portion of the spine. The muscles 
at the back of the neck were in a semi-rigid state, the sterno-mastoid equally 
so ; and in speaking, the action of the labial and nasal muscles gave a sort of 
tetanic cast to the countenance. The jaws were separable, but limitedly so, 
admitting a finger to pass between them. The tongue was easily protruded, 
but yet with a sort of spasmodic jerk. The head was almost fixedly retained 
in the horizontal position, the lower jaw at the same time projecting forwards, 
as if to accommodate the pharynx in its functions. The elevation of the head 
or its lateral movement was wholly impracticable, and from the manner in 
which they were performed, gave a very peculiar stamp to the countenance. 

1850.] Medical Pathology and Therapeutics. 193 

On stripping the thorax, a lateral curvature of the spine was visible; there was 
also extreme tenderness on pressure over the spinous processes of the cervical 
vertebrae, particularly their central portions. There were yet no other symp- 
toms indicative of caries of the spine ; there were no shooting pains along the 
arms, nor about the lateral portions of the head. In fact, there was, latterly, 
rather a disposition to alleviation than aggravation of the original symptoms. 
The local characters of the abscess were most marked ; there was a general 
blush of the fauces, and immediately behind the soft palate, when the tongue 
was much depressed and at the same time not allowed to protrude, a passing 
glance caught the pharynx bulging forwards in the median line, where, press- 
ure being made with the finger, most unequivocal fluctuation could be felt 
through a tense, elastic, membranous wall. The boundary of the abscess above 
could be measured by the finger with ease, but below it was gradually bevelled 
off, the sensation of fluctuation being communicated throughout. Dr. Mont- 
gomery's opinion being confirmed, the opening of the abscess was decided on, 
and effected by an ordinary sharp-pointed bistoury, protected to about half an 
inch from the point. In proceeding to open it, I depressed the tongue well 
with the fore-finger of the left hand, and endeavoured to cloak the glottis on the 
escape of the pus. The opening was accomplished with ease, and was made 
in a transverse direction ; a large gush of matter darted forwards, so as to fill 
the depressed cavity of the tongue, and more escaped by pressure from below 
with the finger passed into the mouth. The child expressed herself much re- 
lieved, and her attendant remarked she was able to raise up her head. I 
fancied, also, that its lateral movements were effected with more ease. On the 
ninth day after the opening of the abscess, I again saw this little girl ; she 
expressed herself as being much better ; the varied movements of the head and 
neck, though yet imperfect, were much improved. On examining the throat, 
the site of the opening presented an ulcerated margin ; it was exactly in the 
median line, and could be seen without much difficulty. On introducing the 
finger into the pharynx, much fulness was discernible, and I could discover 
that this extended a good way below the level of the opening. I satisfied my- 
self no matter was lodged in the abscess; its anterior wall appeared as if 
detached from the spine, and it occurred to me that air might have kept it so. 
Syrup of the iodide of iron was directed, tepid salt-water bathing recommended, 
and every attention to improve the general health enjoined ; Dr. Montgomery 
and I coinciding in the opinion that in this case it was to be apprehended some 
lesion of the vertebrae existed. 

January, 1850. I have heard from Dr. Montgomery that the child has re- 
coverd from all previous symptoms, with the exception of a certain limited and 
studied movement of the head, and that the general health is perfectly re- 

The details of the above cases are given so much at length that it is almost 
unnecessary to add any remarks. The second case requires none. The age 
of the child, and the chronic character of the abscess, with the other attendant 
local symptoms, assisted in removing any difficulties which might otherwise 
arise, and no hurried measures were called for on the part of the surgeon. Its 
favourable termination, notwithstanding the more than probable connection of 
the abscess with spinal disease, is, perhaps, its most remarkable feature. 
Not so the first case ; there, the tender age of the patient, the extreme acute- 
ness and urgency of the symptoms, necessarily equivocal in their nature, and 
their purely local cause, tended most materially to obscure the diagnosis. I 
have recorded a case somewhat doubtful at the age of four weeks, but I have 
never before met with one so unequivocal in its nature at a younger period 
than four or six months. I have brought these cases forward at present, even 
at the risk of repetition, from the conviction of their importance in the cata- 
logue of diseases to which children are liable, and from the impression on my 
mind that such affections of the throat too often escape observation; hence 
many children must fall victims to them, and many are subjected to treatment, if 
not inimical to, certainly wholly unfitted for their relief — treatment, from the 
nature of the attendant symptoms, necessarily active and severe. To my for- 
mer communication on this subject I have little to add; the cases now reported 

194 Progress of the Medical Sciences. [July 

are but a confirmation of the statements then made. — Dublin Quarterly Journ., 
Feb. 1850. 

27. On a Peculiar Disease of the Nasal Fossa. — Dr. John Gairdner read to 
the Edinburgh Medico-Chirurgical Society, the following case : — 

" The subject of my narrative was about fifty years of age, when he became 
affected with a common coryzaof no unusual severity. While labouring under 
it, he was called to a piece of professional duty at a considerable distance. It 
was early in May, and he had to travel twelve miles of his journey in an open 
vehicle, and under a chilly atmosphere — the last four miles being after sunset. 
His coryza was thus very sensibly increased, and it became still more trouble- 
some after his return. A week after the date of his journey he was obliged to 
take to bed for four days, in consequence of feverishness, headache, and excess- 
ive coryza ; which last symptom was then, for the first time, attended with a 
most distressing fetor. The fetor proceeded exclusively from the right nostril, 
from which also the discharge chiefly came. The matter was thick and opaque. 
There was considerable pain in the right superior-maxillary region, and also 
behind the mastoid process, at a point about one inch below the insertion of 
the right trachelo-mastoid muscle. The discharge, which was at first excessive, 
gradually diminished, along with the other symptoms, and he was enabled to 
resume his professional duties in less than a week from the time he took to 

Such was the commencement of a disorder which hung about him, in a sub- 
dued form, for several years. After the subsidence of the acute symptoms, his 
ordinary condition was as follows : — He had — 1, a constant sense of partial 
obstruction of the right nostril, requiring some degree of force to impel air 
through it ; 2, more than the usual amount of mucous discharge from that 
nostril ;'3, inability to incline his head forward without causing a necessity for 
the use of his handkerchief; 4, fetor, not constant, not even frequent, as it 
occurred only once or twice a-day, and for a minute or thereabouts at a time ; 
rarely perceptible by others ; always accompanied, when it did occur, by a 
sensation of the escape of some fluid into the affected nostril: and usually fol- 
lowed by the discharge of a pellet of matter, which was thicker and yellower 
than the ordinary mucus of the nostril ; 5, pain in the region of the right supe- 
rior maxillary bone ; it was a dull pain, not constant, but seldom absent for 
above a day, or two days at most. 6. To these things, I must add that the dis- 
charges from the two nostrils, microscopically examined, presented very diffe- 
rent characters — that of the right nostril containing pus globules, while that of 
the left exhibited no characters at all different from those of the healthy secre- 
tion of the Schneiderian membrane. All these symptoms, and especially the 
fetor, were immediately and greatly increased by every inflammatory cold which 
affected the nasal fossa. 

After the lapse of seven years and a half from the first invasion of this dis- 
agreeable disorder, he was lately seized with a catarrhal affection, accompanied 
by coryza, fetid discharge from the nostrils, and some headache. The attack 
was in no respect different from many attacks which he had had at various 
periods for some years before it. But, immediately after its cessation, he re- 
marked with satisfaction that the fetor was gone, and the habitual discharge 
from the right nostril greatly diminished. The sense of obstruction in the 
nostril, the stillicidium upon inclining the head forward, and the pain in the 
maxillary region, had all undergone a great change for the better. The change 
has been progressive — and he is now so free from all these symptoms that his 
cure may be regarded as nearly complete. 

On a retrospect of this case, it appears probable that the exposure in which 
it originated had caused the death of a minute portion of bone within the nos- 
tril, possibly of a part of the spongy bone, and that the exfoliation of this por- 
tion was the cause of the cure. That its escape was not observed by the patient 
is not against this supposition ; as a very inconsiderable fragment would suffice 
to account for everything. 

It may be right that I should make this history complete, by stating that the 
•patient is of a healthy constitution, that he has not been subject to glandular 

1850.] Medical Pathology and Therapeutics. 195 

swellings, or any form of strumous disorder, that he never took mercury except 
in the form of a purgative of calomel, and that not half a dozen times in his life, 
so far as he can remember ; and that he never in his life had any description 
of venereal disorder. 

Two things must be mentioned with regard to his family. One is, that his 
mother certainly suffered from some analogous affection some years before her 
death ; she did not indeed complain of it, and therefore he cannot supply any 
minute information about it ; but her handkerchief gave sufficient evidence of 
more than usual discharge from the nostrils, and of its being thick, and, as he 
thinks, somewhat fetid. 

The other fact alluded to is of more interest. His brother, who is also of the 
medical profession, experienced a similar attack in his own person. In him 
the complaint did not supervene suddenly, but was the result of repeated and 
neglected colds. For forty years of his life he scarcely ever required the use 
of a pocket-handkerchief. For two years he used two every day ; and, when 
dry, they were always glued together in the manner that is caused by a dis- 
charge from an excited mucous surface. The discharge was manifestly fetid at 
times, though not constantly. This was not felt by himself, for the sense of 
smelling was then, and still continues to be, much blunted. After two years, 
during which time the discharge had flowed pretty copiously, and at times so 
freely as to be a very great inconvenience, a gradual abatement was observed ; 
and, about this period, he was aware of some traces of osseous matter. The 
right nostril was much more affected than the left, but his pain was confined to 
the reigon of the frontal sinuses, and was dull, not acute. He has still a con- 
stant moisture of the right nostril, which becomes copious, not with colds only, 
but with any disturbance of health, and has occasionally fetor. He thinks the 
sense of smelling is returning. He still uses a handkerchief every day ; but 
he remarks that when it is dry it is not now, as it formerly used to be, hard 
and stiff as a board. It is, therefore, evident that a great change has taken 
place, indicating a diminution of fibrinous exudation, and an approximation to 
a cure of his disease. 

Under the title ozoena, in a variety of systematic works, will be found descrip- 
tions of a form of disease similar to the above, which are usually accompanied 
by an unfavourable opinion with regard to the chance of its removal. The 
prognostic, I have no doubt, is well founded in many instances. But I am in- 
clined to think that where, as in the cases just related, there is neither cancer, 
nor struma, nor syphilis, nor mercurial erethism to contend with, the case will 
generally end in a cure. It is probable that such cases are seldom watched 
from beginning to end by those who have described them, and that they have 
therefore sometimes been erroneously judged incurable merely on account of 
their tediousness. — Monthly Journal, April, 1850. 

28. Erythema Nodosum. — Br. Begbie read to the Medico-Chirurgical Society 
of Edinburgh (March 20th, 1850), a communication on erythema nodosum, 
and its connection with the rheumatic diathesis. After some remarks upon 
the advantage of studying the symptoms which indicate the morbid state of 
organization on which diseases depend, and which are apt to be neglected by 
the superficial observer, Dr. B. proceeded to describe the eruption and course 
of erythema nodosum. He then detailed some very interesting cases from his 
own practice, in which the appearance of the eruption was preceded by a state 
of general cachexia, resembling that which is observed before an attack of 
rheumatism. In some of the cases there were deep-seated pains in the limbs 
and joints, and, in the course of the disease, abundant acid perspirations, and 
deposit of lithates in the urine. The sulphate of quinia had been recommended 
by Dr. Watson as useful in erythema nodosum, and in Dr. Begbie's practice it 
had always proved efficacious. The use of bark in rheumatism had been long 
ago recommended, and still had its advocates among the best informed physi- 
cians of the day. The connection between the skin disease and rheumatism 
was inferred, lstly. Because erythema nodosum, rheumatism, and the rheuma- 
tic diathesis are most frequently, if not exclusively, confined to the young and 
those under thirty years of age. 2dly. Because these diseases are frequently 

196 Progress of the Medical Sciences. [July 

associated with disorders of the menstrual function. 3dly. Because a disor- 
dered state of the general health, characterized by pallor, cachexia, and defect- 
ive excretion, precedes the eruption, and is subsequently developed in febrile 
excitement, pains in the joints and muscles, and copious lithic urinary deposit — 
symptoms all common in rheumatism. 4thly. The erythema is often associated 
or alternates with rheumatic fever, and is often complicated with those internal 
disorders with which rheumatism is allied, particularly pleurisy and pneumo- 
nia. 5thly. Remedies of reputed efficacy in rheumatism, such as quinia, are 
equally efficacious in erythema nodosum. Dr. B. pointed out the practical im- 
portance of bearing in mind the connection which seemed to exist between 
these diseases, and, in particular, of not neglecting the disordered state of the 
digestive and assimilating functions — often the only departure from health 
which the physician is called upon to treat for days, or even for weeks, before 
the appearance of erythema, or the occurrence of a paroxysm of acute rheuma- 
tism. — Monthly Journal of Medical Science, May, 1850. 

29. Therapeutical Effects of Turpentine. By Thomas Smith, M. D. — The dis- 
eases for which turpentine has been prescribed, and which have been materially 
relieved by it, are extremely numerous; there is scarcely one, whether acute 
or chronic, sthenic or asthenic, which has not been successfully treated, if the 
testimony of some of the first practitioners of the age is to be credited, by the 
medicine under consideration. It would be a useless task to cite all the cases 
and all the maladies in which the admirers of this drug have found it advan- 
tageous. Suffice it to say, that in every instance where prejudice has not in- 
terfered, and where ignorance has not prescribed, this drug has obtained favour 
and proved itself a faithful friend. 

In passing in review the numerous disorders for which it has been ordered, 
as I wish this paper to have a practical bearing, I shall dwell as briefly as posi- 
ble upon all those which have not come under my own immediate observation. 
Those who desire a more extensive acquaintance with the nature, properties, 
and uses of this drug than is to be met with in these sketches, will do well to 
consult the pages of our monthly and weekly periodicals, which, for the last 
thirty years, have occupied a prominent place in the medical literature of 
Europe and America. The writings of Dr. Copland, Paris, Pereira, Eberle, 
Thompson, Brande, etc., the Dictionnaire de la Matiere Medicate, and the records 
of ancient medicine, contain an amount of valuable information regarding the 
properties of turpentine. In common with other medicines, its therapeutic 
effects are liable to be modified by numerous circumstances : viz., the seasons 
of the year, the idiosyncrasies, age, or sex, of the individual, the special or 
general cause of the malady, or its occurrence before, or subsequent to, any 
general or universal epidemic. * From a neglect of these precautions, many 
really valuable remedies have, though somewhat undeservedly, fallen into dis- 

As a rapid and safe counter-irritant, there is no drug more efficacious than 

* It is a remarkable fact that after any severe visitation, such as epidemic cholera, the 
human frame undergoes an extraordinary change. Many will, J have no doubt, recol- 
lect how general was the custom to abstract large quantities of blood in fevers and in- 
flammatory disorders previous to 1831. Venesection was the practice of the day. On 
the advent of the epidemic influenza of 1833, general bleeding, even in maladies of a 
high phlogistic character, could not be adopted with safety; numerous lives were doubt- 
less sacrificed, ere this change in the human constitution — its inaptitude to bear excess- 
ive depletory measures, was fully appreciated and understood. We are now approach- 
ing an epoch (if we have not already entered it), in which the vital phenomena of the 
animal organism will manifest themselves differently under the influence of remedial 
agents. If my observation does not deceive me, I am inclined to believe that this great 
climacteric change, on the completion of the cycle of the late formidable and universal epi- 
demic, will mainly develop itself, by inducing a lax condition of the intestinal tube. I 
have noticed, that patients who have been accustomed to take large quantities of aperi- 
ent medicine, now rarely require it ; and when it is needed, a smaller portion is found 
sufficient. This is not confined to the aged, for even in children I have witnessed a 
similar alteration in their former habits. 

1850.] Medical Pathology and Therapeutics. 197 

warm oil of turpentine or camphine. I have never known an instance of its 
acting injuriously when thus applied; it never produces strangury or any un- 
easiness of the urinary organs, like preparations of cantharides ; and here I 
fully coincide with the opinion expressed by the late Dr. Kyan, that when 
counter-irritation is deemed imperatively necessary in severe acute diseases, 
as cerebritis, hydrocephalus, pneumonia, enteritis, peritonitis, or hepatitis, it is 
an extremely inert and unjustifiable practice, to wait for twenty-four hours for 
the irritating effects of a blister, when the same may be produced in as many 
minutes by epithems of warm oil of turpentine. 

Veterinary surgeons have condemned the external use of turpentine as an 
epispastic ; it has been asserted that, when applied to the horse, it prevents the 
hair from growing. I do not think this correct. Some years ago I had a gray 
mare, which was seriously injured about the head and forelegs by an accident. 
Contrary to the recommendation of my veterinary surgeon, who insisted upon 
the application of tincture of myrrh, and greasy unguents containing gun- 
powder, I determined for once to try the experiment, if an injury to a horse 
might not be remedied by the same means as one in a human subject. I had 
the wounds carefully fomented and poulticed, and afterwards applied an oint- 
ment, consisting of resin ointment and oil of turpentine. The animal re- 
covered without any material disfigurement. Last year I had a black horse 
consigned to me by a friend in Yorkshire, which met with a severe accident in 
its transit on the railway. The horse was treated in the same way as the one 
above, and in a few months was perfectly restored, without any other blemish. 

The liniment, by means of which the celebrated quack St John Long was 
supposed to have performed miraculous cures, was a mixture of the oil of tur- 
pentine, pyroligneous acid, and yolk of egg.* 

As a vermifuge, turpentine has been given in the form of Chabert's oil. This 
is made by mixing one part of the empyreumatic oil of hartshorn, with three 
of oil of turpentine, allowing them to stand for three days, and afterwards dis- 
tilling off three-fourths of the mixture by the aid of a sand bath. It very 
soon becomes blackened, by exposure to the air, and therefore ought to be kept 
well corked, and excluded from the light. It is extremely nauseous ; and, on 
that account, is not likely to come into general use. 

As & purgative, turpentine ought never to be administered alone, in large 
doses, during the winter, or in cold damp weather: because under these cir- 
cumstances, it tends, in common with other hydrocarbons, to supply fuel to the 
body for the evolution of animal heat, rather than exert any therapeutic pro- 
perty. Indeed, I very much question the propriety of giving it alone, as a 
purgative under any circumstances whatever. There are some writers who do 
not hesitate to recommend it in doses which I consider unjustifiable. In win- 
ter, cerebral congestion may supervene ; in summer, intractable diarrhoea, 
from over-excitement of the mucous membrane of the bowels. The case of 
Dr. Copland furnishes an instructive example on this head: ten drachms of 
the oil of turpentine were swallowed, and failed to induce action of the bowels 
or kidneys ; the consequence was, high cerebral excitement, followed by a train 
of unpleasant symptoms, which it would be dangerous, in some constitutions, 
to excite. 

Turpentine is, however, often a valuable addition to other purgatives, as it 
possesses the faculty of increasing their activity in a remarkable degree. I 
have known a lady, who, for forty years, was unable to procure an evacuation 
without the most drastic purgatives. She succeeded in obtaining daily action, 
by the simple combination of a teaspoonful of castor oil with ten drops of oil 
of turpentine. I have had another case under my care, where the same com- 
bination enabled me to relieve the augmented suffering occasioned by obstruc- 
tion of the bowels from chronic meningo-myelitis of several years duration. 

Whatever may be the object for which turpentine is exhibited as a purgative, 
whether for the expulsion of parasites infesting the human body, or as a revul- 

* This liniment is an excellent counter irritant. We used it as an external stimulant 
in some cases of cholera during the past epidemic, as recommended by Dr. James Bird; 
and we frequently employ it as a counter-irritant in phthisis, and other chest diseases, — 

198 Progress of the Medical Sciences. [July 

give in cerebral affections, the dose should never exceed half an ounce at one 
time ; and to insure its purgative action, it ought to be united with some other 
aperient, as castor oil, compound infusion of senna, sulphate of magnesia, or 
the decoction of the bark of the root of the pomegranate. If prescribed in the 
above dose, in conjunction with any other active purgative, we run little risk 
of inducing strangury, or any other unpleasant symptom. It maybe repeated 
at intervals of four hours, with perfect safety. Though some authors have 
stated that the dose of the oil of turpentine may be from half an ounce to 
two, or even four ounces, he must be a very bold practitioner who would take 
this suggestion for his guide. If the first-named quantity will not suffice for 
the destruction and consequent expulsion of a taenia, a larger amount given at 
one time will equally fail; for it is not by the aperient properties alone of the 
medicine (as I shall hereafter show) that the death of the worm is effected.* 
As a diuretic, the dose may be from five to thirty drops, taken in any aromatic 
water, or mineral saline. I have rarely found patients object to its use, when 
exhibited with the salines of either Cheltenham or Harrowgate ; and the numer- 
ous cases in which I have prescribed it, in conjunction with the waters from 
these mineral springs, have convinced me, that this union is especially indicated 
where we are anxious to direct its influence to the renal organs. 

As an astringent, in doses varying from 20 minims to a drachm, according to 
the urgency of the symptoms, and repeated every three or four hours, turpen- 
tine is one of the most efficacious remedies which we possess. The best vehi- 
cle for its administration, in the first place, is water, flavoured with syrup of 
orange, or any other agreeable aromatic. It may afterwards be advantageously 
combined with any other therapeutic agents, which the special nature of the 
case may require : thus, in epistaxis depending upon rupture of one or more 
small vessels, and where much arterial blood has been lost, muriated tincture 
of iron will form a valuable adjunct. In hsematemesis and other sanguineous 
discharges from the bowels, it may be united with compound infusion of roses, 
sulphate of magnesia, iced-water, and solutions of tannic or gallic acid. In 
some forms of haemoptysis, it may usefully be added" to infusions of matico; in 
haematuria, to the decoctions of uva ursi, chimaphila, pyrola, etc. ; or to tinc- 
ture of sesquichloride of iron, etc. In purpura hemorrhagica, the decoctions or 
infusions of the barks form with it an excellent adjuvant. In haemoptysis, it 
has speedily and effectually arrested the hemorrhage; and is a much safer 
remedy than lead. 

In my experience, there is no single medicine in the materia medica that 
can be compared with it as a styptic, either as to certainty of action or to the 
safety of its effects. It is compatible alike with acids and alkalies. 

The external use of turpentine has been very general for a great number of 
years, alone or combined with other rubefacients, such as mustard, strong 
liquor ammoniae, pyroligneous acid, cajeput oil, wine of hellebore, colchicum 
or opium, tartar emetic, croton oil, etc. It has very frequently been found of 
permanent utility, when applied as a warm epithem to the skin in pulmonary 
affections. Its action is twofold ; first, it induces rapid though often transient 
counter-irritation ; secondly, its vapour is inhaled into the lungs, and by its 
constringent operation on the extreme capillaries of the pulmonary texture, is 
not infrequently productive of great relief in some affections of these organs. 
For the purpose of inhalation, I am in the habit of dispersing its vapour 
through the room by evaporating water containing a portion of it, by the aid 

* There may be special cases, but they will be extremely few, in which an extraordi- 
nary dose of any particular medicine may be peremptorily called for by the condition of 
the patient. For instance, I once gave to a man labouring under delirium tremens, 
seven grains of the acetate of morphia, in divided doses, within two hours, ere I could 
allay the inordinate and convulsive movements, and restrain the shrieks of the wretched 
sufferer. Again, at another time, I exhibited to a female, in the presence of Dr. Logan, 
twelve ounces of sulphuric ether, when the principles of etherization were first intro- 
duced, and kept this woman in a state of insensibility for upwards of six hours. 
Although both these cases did well, they are exceptional ones, and ought never to be 
imitated, except in emergencies of the most urgent description. 

1850.] Medical Paihohgy and Therapeutics. 199 

of a spirit lamp. When thus diffused through the atmosphere, it may be 
breathed for two or three hours in the course of the day, by the most delicate- 
chested person, and often with the most marked and striking amelioration of 
their pectoral symptoms. 

Long after the patient has left the room, he is conscious of the taste and 
smell of the turpentine. I have often detected its presence some hours after 
he had been submitted to its penetrating influence. I have also employed 
camphine in the form of a bath, mixed with common soda; or two pounds of 
the latter with from a quarter of a pint to half a pint of camphine, and half an 
ounce of oil of rosemary, will form an excellent bath. In delicate skinned 
patients, females and children, §ii of camphine will be sufficient. I may re- 
mark, in limine, that the alkaline camphine bath possesses virtues peculiarly 
its own. In the coldest day in winter, as I have verified in more than one in- 
stance, it may be employed with the most perfect safety. Whilst the indivi- 
dual is in the bath, he experiences, to my knowledge, no disagreeable annoy- 
ance from the disengaged vapour; on the contrary, if we except the taste of 
the turpentine, which for some time remains in the mouth, a sense of calmness 
and tranquillity very often follows a previously disturbed, irregular, or excited 
condition of the respiratory or sanguiferous systems. After five minutes re- 
cumbency in the bath, the pulse is found to become fuller, softer, and slower; 
I have seen it fall from 100 to 80. The respiration also becomes freer, deeper, 
and less laboured. On coming out of the bath, the whole skin has a peculiar 
velvety, soft, and agreeable feeling ; the breath is strongly tainted with the 
terebinthinaceous odour. If it have not been too hot, a pleasurable tingling 
warmth is experienced throughout the whole cutaneous surface ; and this, with 
the preceding symptoms, may continue twenty-four hours. One great advan- 
tage of this bath will be found in the circumstance, that it may be employed 
at a heat from 10 to 15 degrees below the temperature of the ordinary warm 
one, without inducing that sensation of chill to which some delicate constitu- 
tions are so peculiarly obnoxious ; ten or fifteen minutes is the length of time 
a patient ought to remain in a bath of this description. In the first instance, 
it is well for patients to commence with a smaller quantity of the turpentine 
and soda, say a pound of the latter with two or three ounces of the former, and 
gradually increase its strength on each repetition of the bath, to the first-men- 
tioned proportions. This bath may be taken every second or third day, accord- 
ing to the urgency of the symptoms and the nature of the affection for which 
it is prescribed. 

I come now to a more particular enumeration of the maladies for which tur- 
pentine and its preparations have been chiefly recommended. They are — san- 
guineous exhalations from the mucous surfaces, epistaxis, haemoptysis, meleena, 
purpura hemorrhagica ;* consumption, chronic bronchitis, mucous or purulent 
discharges from the urethra;! grubs infesting the urethra, taenia, ascarides;J 
typhoid, yellow and puerperal fevers, plague ;$ abdominal obstructions, strangu- 
lated hernia, tympanitis, colica pictonum, biliary concretions ;|| traumatic 
tetanus, trismus;^ apoplexy, hydrocephalus, acute and chronic, epilepsy;** 
neuralgia, sciatica, rheumatism ;ff diabetes, dropsy \%% inflammations of the 

* Adair, Brooke, Cheyne, Clutterbuck, Copland, Elliotson, Hunter, Magee, Nicliol (W.), 
Thompson, Vincent, Younge. 

f Areta?us, Celsus, Dioscorides, Van Swieten. 

j Birkbeck, Cross, Fenwick, Fothergill, Gom^s, Hancock, Hartle, Kennedy, Knox, 
Laird, Lettsom, Maldon, Mello, Ozanam, Pereira, Saner, Winstone. 

§ Atkinson, Blundell, Brenan, Chapman, Copland, Cullen, Douglas, Farre, Faulkner 
(Sir A. Brooke), Fernandez, Gooch, Hamilton, Hoist, Johnson, Kinneir, Moran, Payne, 
Physick, Pritchard, Wood. 

|| Boerhaave, Durand, Gibbon, Green, Guyton de Morveau, Hall (Marshall), Hamil- 
ton (C. B.), Kinglake, Mac Williams, Odier, Paris, Ram shot ham, Sewell, Sprengel. 

\ Gibbon, Hutchinson, Mott, Phillips. 

** Latham, Lithgow, Money, Moran, Percival, Pritchard, Young. 

ft Bonnet, Cheyne, Ducros, Dufour, England, liild, Home, La Roque, Lenton, Martinet, 
Maton, Pitcairn, Recamier, Thilenius. 

X% Darwin, Werlhoff. 

200 Progress of the Medical Sciences. [July 

eye ;* cholera, renal hydatids, suppression of urine ;f burns, wounds, poisoning 
by prussic acid or opium, salivation. J — Lond. Journ. Med., April, 1850. 

30. Remarks on Vermifuges. — Dr. Cazin, of Boulogne- sur-Mer, having had 
the opportunity of treating a large number of worm cases, has published the 
following interesting account of his experience. He states that he has fre- 
quently employed the common spigelia, or worm-grass. He administers it in 
the form of decoction, prepared by boiling two drachms of the herb in a quart 
of water to one-half. The decoction is then expressed, strained, and flavoured 
with a little lemon-juice and a sufficient quantity of sugar. The dose for an 
adult is two wineglassfuls, followed by a wineglassful every six hours until 
the desired effect is produced. To children and delicate persons a smaller 
quantity is to be given. 

Wormwood (absinthium) is an excellent indigenous anthelmintic ; it is also 
a powerful tonic and stimulant, the use of which, continued after the expulsion 
of the worms, prevents their reproduction. M. Cazin often uses a wine pre- 
pared by digesting an ounce of wormwood, with an equal quantity of garlic, 
in a bottle of white wine, of which he gives from one to three ounces every 
morning. This wine is well-adapted for poor lymphatic subjects, wasted by 
wretchedness, and suffering from the influence of a marshy soil. The absin- 
thium maritimum is likewise a very good anthelmintic. M. Cazin gives it to the 
extent of one or two drachms boiled in four or five ounces of water, with the 
addition of some "white sugar, or of any anthelmintic syrup. This is quite a 
popular remedy in the maritime districts, and almost always succeeds with 
children affected with worms. 

Although a case of poisoning by Cevadilla has been reported, M. Cazin has 
administered this vermifuge with success in cases in which ordinary anthel- 
mintics had but little effect ; but he has always commenced with a very small 
dose, in order to ascertain how far it would be borne by the digestive organs. 
For children, the dose of this plant is from a grain and. a half to four or five 
grains of the powder of the seeds, mixed with syrup of rhubarb; for adults 
eight or nine grains, with the addition of a little sugar and a few drops of oil 
of fennel. In each case the dose is to be repeated daily for four days, after 
which the infusion of chamomile is to be given. 

Assafoetida possesses acknowledged anthelmintic properties, and is suitable 
for cases of sympathetic nervous affections produced by the existence of worms. 
It thus, like valerian, fulfils a twofold indication. In a case of nervous affec- 
tion, which M. Cazin believed to be idiopathic, the administration of assafoetida 
both determined the disease and revealed its true cause, by effecting the ex- 
pulsion of a number of lumbrici. This result has, in three cases of chorea and 
in two of epilepsy, enabled him to recognize that sympathetic irritation — 
depending on the presence of intestinal worms — was the sole cause of disease 
in these instances. Under ordinary circumstances, M. Cazin frequently com- 
bines assafoetida with calomel in pills. This combination, of all those that he 
has employed, succeeds best in expelling lumbrici. He has also combined it 
with black oxide of iron, particularly in anemic patients. Assafoetida may be 
given in powder, in doses of from four grains to half a drachm. 

The essential oil of turpentine is not merely useful in cases of taenia, it is 
also decidedly efficacious in expelling the lumbrici. M. Cazin has sometimes, 
in cases of lumbrici and ascarides, administered with advantage turpentine, 
enemata, prepared by suspending, by means of yolk of egg, from one drachm 
to half an ounce of the oil in decoction of tansy, absinthium, worm-seed (se- 
men-contra), or Corsican moss. 

Common salt is very destructive to worms ; it is given alone in large doses 
dissolved in water ; it should be taken on an empty stomach. M. Cazin also 
frequently administers it in the form of enema, with brown sugar, linseed or 

* Burke, Carmichael, Foote, Guthrie, Hynam, Langier, Middlemore, Wright, 
f Bayle, Copland, Neale, Pereira. 

J Emmert, Geddings, Hanold, Heister, Jenkins, Kentish, King, Orfila, Pare (Am- 
broise), Percy, Pott. 

1850.] Medical Pathohgy and Therapeutics. 201 

poppy oil, and a sufficient quantity of water. With children it almost always 

Like all tonics, iron has the advantage of destroying worms, at the same 
time that, by imparting tone to the intestines, it prevents their reproduction. 
From six to eight grains of iron filings, mixed with an equal quantity of rhu- 
barb, and taken twice or three times a day, have often been sufficient to expel 
the worms contained in the intestines. M. Cazin succeeded in rapidly curing 
a boy nine years of age, emaciated and pale, whose sleep was disturbed, and 
who was suffering from spasmodic movements similar to those which charac- 
terize chorea, by the exhibition of pills of sulphate of iron, combined, ac- 
cording to Fuller's formula, with aloes, senna, &c, under which treatment he 
voided twenty-three lumbrici in four days. He has also used with remarkable 
success Bosen's mixture, containing extract of black hellebore and sulphate of 
iron. But what he chiefly gives to children, as well as to adults, is the syrup 
of citrate of iron (four parts of citrate to sixty of simple syrup, and one of 
essence of lemon), in doses of from two drachms to half an ounce to children, 
and from half an ounce to two ounces to adults. 

M. Cazin remarks that calomel, so efficacious as an anthelmintic, ought never 
to be combined with an alkaline chloride, as the formation of corrosive subli- 
mate would probably ensue from their admixture. In like manner, the combi- 
nation of calomel with cherry-laurel water, or emulsion of bitter almonds, 
would give rise to the development of two formidable poisons, corrosive subli- 
mate and cyanide of mercury. 

The effects of the male fern, tin, pomegranate bark, hellebore, &c, require 
merely to be noticed ; and the properties of the pomegranate root bark are so 
well known that they need not be dwelt upon. M. Cazin has remarked nothing 
particular respecting other anthelmintics. He merely says that cod-liver oil 
has succeeded with him in the cases of two females, one of whom passed twelve 
lumbrici the same day that she had taken in the morning three tablespoonfuls 
at intervals of an hour. 

But, whatever be the medicine selected, we must not, like routine practi- 
tioners, be content, when the worms are killed and dislodged, with this merely 
palliative cure. A very important indication remains to be fulfilled, viz., to 
prevent their reproduction. This object is attained, according to M. Cazin, by 
the adoption of a tonic and stimulant regimen, which must be long continued, 
and, above all, by the employment of bitter and chalybeate preparations. He 
has found the ferruginous chocolate to be sufficient, in the case of children, to 
prevent the relapses which are for many years very apt to occur. Wine taken 
while fasting has succeeded with the poor inhabitants of the marshes, accus- 
tomed to live only on vegetables and milk ; and he has also remarked its efficacy 
as a preventative of worm affections in other instances. 

To these observations of M. Cazin, the editor of the Journal de Medecine has 
appended the following practical remarks. The number of experiments tried 
by M. Cazin leaves no room for doubt respecting the enormous amount of worm 
affections which he must have met with. Such a result may appear strange to 
Parisian physicians, who attribute to the presence of worms in the intestines 
only a very trifling influence over the symptoms formerly ascribed to them. 
But if worm affections are rare among the inhabitants of large towns, they are 
frequent and generally more serious among the peasantry, and particularly 
among those who are poor and placed in unfavourable hygienic circumstances. 
We shall, therefore, take the present opportunity of mentioning the efficacy 
of broicn santonine, lately brought under the notice of the readers of the Bul- 
letin de Th&rapeutiqiie, by M. Gaffard, an apothecary at Aurillac. 

The difficulty experienced in procuring pure santonine, both on account of its 
high price, and for other reasons, has induced M. Gaffard to endeavour to obtain 
from worm-seed, a product which may possess the advantages of the former, 
and at the same time be free from the objections to the use of the latter. This 
product he calls brown or impure santonine ; it is obtained in the following 
manner : — 

Take of Aleppo worm-seed, three ounces ; carbonate of potash, one ounce ; 
slacked lime, sifted, half an ounce ; water, from three pints to three pints and a 
half. Place the mixture on the fire, stirring occasionally with a wooden spa- 

202 Progress of the Medical Sciences. [July 

tula ; let it boil for an hour ; on removing it from the fire pass it with expres- 
sion through a linen cloth, let it settle, decant, and add hydrochloric or nitric 
acid until it reddens litmus without being sensibly acid to the tongue. Allow 
it to rest, pass it through a filter previously moistened, or through a piece of 
close canvas, and allow the product which remains on the filter to dry in the 
open air until it acquires the consistence of firm butter. This product, which 
is a mixture of santonine, resin, and essential oil, will answer for the various 
pharmaceutic forms in which the practitioner may wish to exhibit it. M. Gaf- 
fard gives it in the form of lozenges composed as follows : — 

Brown santonine, three drachms ; powdered sugar, thirteen ounces ; pow- 
dered gum, one ounce and a half; essential oil of lemon, twenty-five drops. 
Place the brown santonine in a marble mortar ; add by degrees, and with con- 
stant trituration, the sugar mixed with the essential oil and the gum, so as to 
make a homogenous powder. Form with a sufficient quantity of water a mass 
of the desired consistence, and divide it into lozenges, each of which shall 
weigh, when dried, fifteen grains ; each lozenge will then contain somewhat 
more than one-third of a grain of brown santonine. 

For infants under six months the dose will be one lozenge night and morning ; 
from six months to a year, two lozenges night and morning ; from one to two 
years, three, and from two to four years, four night and morning ; for children 
of five years and upwards a lozenge for each year of the child's age should be 
given night and morning. The medicine to be continued until the desired 
effects are no longer produced. — Journal de Medicine et de Chirurgie Pratiques, 
March, 1850. 

[A remedy for tape-worm, which has been for some time employed in France 
under the name of kousso, has been recently tried in King's College Hospital, 
London, with marked success. It is an infusion of the dried flowers of the 
Brayera anthelmintica, a native of Abyssinia, in which country it is a popular 
remedy for this worm, which is very prevalent amongst the inhabitants. A 
single dose, which is prepared by macerating for a quarter of an hour half an 
ounce of the dried flowers powdered in half a pint of luke-warm water, is taken 
at a draught, the suspended powder being all swallowed. Lemon juice may be 
taken before and after the dose. It usually brings away the worm in an hour 
or two after it has been taken. Those who have tried this remedy state that it 
is equally safe as effectual ; and the only objection to its employment is its high 
price at present.] — Dublin Quarterly Journal, May, 1850. 

31. Treatment of Chorea. — M. Faivre D'Esnans mentions, in the Journal de 
Medecine et de Chirurgie Pratiques, that he has obtained the happiest results 
from the prussiate of iron in chorea and epilepsy, and he gives several cases 
where the cure was obtained in between four and eight days. He uses the fol- 
lowing formula: — Prussiate of iron, fifteen grs., extract of valerian, forty -five 
grains ; make twenty-four pills. One pill to be taken three times a-day, at six 
hours' internal, each pill to be followed by a wineglass of infusion of valerian. 
The author was induced to try the prussiate of iron, from having seen M. 
Jourdes use it, at the Military Hospital of Strasburg, for intermittent fever. 
As he considers that both diseases (chorea and ague) have their seat in the 
medulla spinalis, he thought that the same remedies would prove efficacious in 
both complaints, in which supposition, according to his statements, he was not 
deceived. Dr. Zollickoffer, of Maryland, used it many years since in intermit- 
tent and remittent fevers, dysentery, &c, and highly extols its powers. (See 
Philad. Jour n. Med. and Phys. Sc., vol. vi., 1823.) 



32. Diseases of the Membrana Tgmpani. — Mr. Totnbee exhibited to the patho- 
logical society of London (March 18, 1850) an extensive series of preparations 
illustrative of the diseases of the membrana tympani: — 

He remarked that time would not allow him to do more than indicate briefly 

1850.] Surgery. 203 

the principal pathological conditions to which this structure is liable. In the 
first place, he would point out the diseases to which each of the component 
structures of the membrana tympani is liable, independently of the others ; and, 
in the second place, describe those in which all its structures were implicated. 

The external or epidermoid layer of the membrana tympani is found in two 
diseased states ; the first is hypertrophy, in which it becomes many times thicker 
than natural, and forms a dense laminated mass, which adheres to the outer 
fibrous layer; the second diseased state is where it is slightly thicker than 
natural, its surface being studded by numerous small round masses, and in this 
state it adheres to the fibrous layer much more firmly than natural. Before 
referring to the diseased conditions of the fibrous laminae, it is requisite to ob- 
serve that it not only consists of two sets of fibres, the radiating and circular, 
but these sets of fibres form two distinct layers, easily separated from each, 
other, and subject to diseases wholly independent of each other. Thus it will 
be often found that the outer or radiating fibrous layer is thicker, whiter, and 
more dense than natural, while the internal circular fibrous layer is perfectly 
healthy. In other cases, the internal layer is much thickened, while the outer 
layer is translucent and healthy. The external surface of the outer layer is 
frequently the seat of chronic inflammation, when it becomes very thick and 
vascular, and is covered by granulations of a deep red color; polypi are also 
developed from it. Chronic inflammation of the outer layer of the membrana 
tympani frequently induces ulceration, by which process portions of one, often 
of both of the fibrous laminse are destroyed, while the mucous membrane re- 
mains entire. In cases where only a small portion of each of the fibrous laminae 
has thus been removed by ulceration, a deep depression exists ; caused by the 
mucous membrane bulging inwards. Where much of the fibrous coats has been 
destroyed, the mucous membrane falls inwards towards the ossicula and pro- 
montory, and becomes adherent to them. The fibrous layers are also the seat 
of calcareous deposit. The internal mucous lamina of the membrana tympani, 
which, in its natural state, is so thin that it is frequently difficult to detect its 
presence, becomes thickened by chronic inflammation, and is sometimes so much 
hypertrophied that its inner surface is in contact with the promontory. In 
acute inflammation, lymph is effused from this mucous layer, and bands of ad- 
hesion are formed which connect it to the ossicula or to the inner wall of the 

The diseases of the membrana tympani in which all its component structures 
are at the same time affected are the following : — 

1. Hypertrophy, where the epidermoid, fibrous, and mucous layers are thick- 
ened. This not unfrequently proceeds to so great an extent that the membrana 
tympani is ten, or even twenty times its natural thickness, and it becomes 
opaque, hard, and dense, like a piece of cartilage. 

2. Ulceration, where all the layers are destroyed wholly, or only in one part, 
so as to cause a perforation. 

3. An increase of the external concavity, so that its external surface is in con- 
tact with the promontory, to which it is frequently firmly adherent. 

4. An absence of the external concavity, in place of which it is perfectly flat. 

5. Scrofulous degeneration, in which all the layers lose their natural structure. 

6. Calcareous degeneration, in which there is often not a vestige of healthy 
structure in any of the layers. 

7. An increased degree of tenseness. — This state is most frequently accompanied 
by the presence of membranous bands, which connect its inner surface to the 
promontory, stapes, or other parts of the inner wall of the tympanum. 

8. Sometimes the whole of both fibrous coats are destroyed by ulceration, and 
the mucous layer remaining entire falls inwards, and covers the surface of the 
promontory and the inner wall of the tympanum. 

9. Sometimes one half of the membrana tympani is destroyed, and the border 
of the remaining half becomes adherent to the inner wall of the tympanum, 
forming a closed cavity. 

10. The entire substance of the membrana tympani is sometimes ruptured. 
The part most subject to rupture is that between the posterior margin and the 
handle of the malleus. — London Med. Gaz. April 12, 1850. 

204 Progress of the Medical Sciences. [July 

33. Caries of the Head of the Femur. — Mr. Henry Smith exhibited at the 
Westminster Medical Society (January 26th, 1850), two specimens, both of 
which had been excised during life. The first had been removed by Mr. Morris, 
of Spalding, from a youth, eighteen years of age. This instance was eminently 
successful.* The other specimen was obtained by him (Mr. S.) from an adult, 
between thirty and forty years of age, formerly in the Grenadier Guards. He 
had removed the diseased bone two years ago. The patient. survived the opera- 
tion six months. This last-named specimen, which had been macerated in 
warm water for three months, exhibited the early stage of caries ; the disease 
had only existed eighteen months ; the globular shape of the head was un- 
changed, but it was carious (honey-combed) all over. The neck of the bone 
was altogether unaffected ; it remained of the usual length, and at the ordinary 
oblique angle with the head. In the other case, the disease had been in exist- 
ence six years, and the head of the bone was completely flattened out, the neck 
being almost destroyed. Instead of an oblique arch, it presented a right angle 
with the head. In his own case, all the symptoms of dislocation of the head 
of the femur existed, and the operation proved his diagnosis to be correct. In 
Mr. Morris's case, it was supposed that dislocation had taken place, but this 
was proved not to be the case, when the operation was performed. A difficulty 
was experienced in dislocating the head, owing to a small piece of bone, which 
had separated from it, and lay in one of the sinuses. It was this which caused 
the symptoms simulating dislocation. There was very great shortening of the 
limb, in consequence of the destruction of the neck of the bones. He had often 
been asked as to the manner in which locomotion could be performed without 
a hip-joint: but when the head of the femur was excised, a new joint might 
soon be formed. After the removal of the diseased bone, inflammation set in, 
lymph was thrown out in the acetabulum, (if healthy) the head of the femur 
became rounded off, and fibrous tissue was formed, from which resulted an 
entirely new capsule. Mr. Morris's patient was able to flex the mutilated thigh 
on the pelvis, as readily as the other, seven weeks after the operation. He had 
seen, a few days since, a woman who had been operated on by Mr. Fergusson 
a year ago ; she was able to walk, with the aid of a high-heeled shoe, without 
a crutch. 

At a subsequent meeting (February 2d) of the same society, Mr. Hatnes 
Walton exhibited three specimens of caries of the head of the femur, removed 
during life, to show the alteration in form and structure, effected by morbus 
coxarius. The first was taken from a girl, nine years old. In place of the 
head and neck, there was a rounded and spongy portion of bone, projecting 
little more than half an inch from the femur. She made a good recovery. The 
second was from a lad, twenty years old. The head was nearly gone ; the neck 
was of the natural size, but so soft that it broke in two during the operation. 
The third was from a boy, eleven years old. Part of the head was lost, and 
the neck was shortened and reduced in size. Mr. Walton was anxious to dis- 
cover some diagnostic signs by which dislocation could be ascertained. The 
change in the form of the bones he had shown, would cause all the symptoms 
of dislocation. The limb would be shortened and the trochanter elevated, and 
brought nearer the pelvis. From the position of the limb, nothing could be 
learned ; it may be turned inwards or outwards; and the thigh may be flexed 
on the pelvis or extended. — London Journal of Medicine, March, 1850. 

34. Case of Perineal Abscess in which the pus made its way into the scrotum. — 
Mr. Rumley related to the Surgical Society of Ireland (March 23d) the particu- 
lars of a remarkable case in which purulent matter, unconnected with urinary 
extravasation, made its way from the perineum into the scrotum. The chief 
circumstances of the case were the following: — A man, who was engaged as a 
clerk in a solicitor's office, called at his house on the 19th of March, 1850, and 
told him that he had suffered from severe pain about his fundament, as he 
termed it, during the last five or six days, and that he was apprehensive he was 

* This case has been published by Mr. Morris in the Provincial Medical and Surgical 
Journal fur February 6, p. 57, as well as in other periodicals. 

1850.] Surgery. 205 

about to get a fistula. On making an examination, he found between the tube- 
rosity of the ischium and the ramus of the pubis a tumour, which was red, 
painful, and fluctuating. There could be no doubt at all that matter had col- 
lected in this situation, and accordingly he advised the man to have it opened 
without loss of time. He declined to allow the operation to be performed then, 
having some pressing business to transact in the Four Courts ; but on arriving 
there, the tumour became so painful that he was obliged to take a car and re- 
turn home. On the way home, the wheel of the car came against a brick, but 
the jolt he received caused him scarcely any pain, and in fact from that moment 
he could sit much easier upon the car. At half past five on the following 
morning, a messenger called at his house to say that he was exceedingly ill, 
and was suffering from violent pain in the scrotum. On throwing back the 
bed-clothes, he remarked that the scrotum was very much enlarged, reddened, 
and tender to the touch. On examining the perineum, the tumour he had seen 
there on the previous day was nearly gone, but the part still retained more or 
less of a doughy feel. It now occurred to him for the first time that the matter 
which had formed the perineal tumour might have found its way into the 
scrotum. He was at a loss to account for the manner in which it had got there, 
but still thought it would be right to make an incision into the perineum, on 
doing which exit was given to a small quantity of a rather good description of 
matter. On the following morning he again saw the man, but he did not deem 
it necessary to make any further use of the knife on that day. When he called 
on the next morning he observed a small blue spot upon the scrotum, about the 
size of a fourpenny piece, and he then made an incision into the scrotum, and 
gave discharge to a small amount of matter. Two days later a slough appeared 
on the scrotum, and in fact a large portion of the cellular substance beneath 
the integuments had sloughed away. During the whole progress of the case 
there were none of the signs of urinary irritation present. It was usually 
imagined that purulent matter was so innocuous that it would not destroy to 
any great extent the tissues with which it came into contact; but in this instance 
a considerable amount of destruction had taken place, though not by any means 
to such an extent as he had seen in other cases. In this case the patient lost 
a portion of his scrotum of about the size of a half-crown piece. From day to 
day the patient became better and better ; granulations started up from the 
tunica vaginalis, and he was then, he might almost say, completely recovered, 
having some days since returned to his usual avocations. He thought the case 
interesting from this circumstance, that if he had not seen the man on the day 
he first called upon him he was almost sure he would not have taken such a 
decisive view of the case as he had : for if he had not seen him till the following 
day, he would not have found sufficient evidence in the perineum to convince 
him that the mischief was situated there ; but having in the first instance seen 
the tumour in that locality, and this having disappeared before the next morn- 
ing, he was at once led to adopt a safe and certain line of conduct. 

Dr. Butcher mentioned the following additional facts, which appear to bear 
out the inferences of Mr. Kumley. On pressing the perineum with the fingers, 
the matter which had there accumulated could be forced along the expanded 
perineum towards the opening in the scrotum; in fact, it could be made, by 
means of pressure, to waive backwards and forwards between the perineum and 
the scrotum. Again, during the examination, the man passed water in a full 
stream, and of course had any communication existed between the urethra and 
the abscess, it was almost certain that a portion of urine would have got through ; 
but in point of fact he could propel his water to a considerable distance from the 
orifice of the urethra, proving that the muscular power was quite strong enough 
to have caused extravasation of urine, if an aperture had existed in the urethra. 
—Dublin Med. Press, April 10, 1850. 

35. A Remarkable Case of Relapses in Cancer. — A woman named Valens, get. 
42, entered the Hotel Dieu under M. Jobert, October 30, 1849. She was married 
at 19, and had been pregnant eight times, and her menstruation is, and has 
always been, normal. Her health was quite good until 1834, when she observed 
a small tumour under the right superciliary ridge, and as it gave her severe 
No. XXXIX.— July, 1850. 14 

206 Progress of the Medical Sciences. [July 

pain, it was (in August) removed, when only the size of a grape seed. The 
wound readily cicatrized. Between November 1834 and April 1835, a similar 
tumour was developed in the same spot, causing severe shooting pains, as well 
as throbbing of the eye. M. Cloquet removed it, as well as the lachrymal gland, 
into which the prolongations of the morbid tissue extended. At the end of a 
month all had healed, and for two years nothing else exhibited itself. . She was 
in perfect health, when three little tumours were observed in precisely the same 
spot, and now implicating the periosteum ; the pains, too, having become much 
more intense than those accompanying the others. Moreover, the lachrymal 
gland being removed, there was no secretion of tears, which occasioned a very 
severe burning pain. The eye was very much swelled. She bore with her 
sufferings for three years, and only entered La Pitie, under Lisfranc, in 1842. 
He removed the tissues proceeding from the old cicatrices, and the three little 
tumours, another that could be felt in the larger angle of the eye, one deeply 
imbedded under the superciliary arch, one covered by the bone at the external 
angle, and still another, adhering to the optic nerve. After this operation, she 
found her sight much impaired, and her vision double. The wound healed in 
twenty-six days, and all p^in departed. The periosteum, and a portion of the 
osseous substance to which the tumours adhered, were removed. 

She continued quite well for a year, when another little tumour appeared just 
above the caruncula lachrymalis, and was accompanied with the same pains as 
heretofore. A pupil of M. Lisfranc's removed the tumour, and the patient had 
two more years of rest. At the end of that period, however, the eye became 
again very painful, the seat of suffering being referred to the back part of the 
orbit, while a new tumour appeared at the place whence the last had been re- 
moved. Four years she bore her suffering ; when, the pain having at last become 
quite insupportable, and the power of distinguishing objects by the eye lost, she 
placed herself under M. Jobert, in April, 1849. He extirpated the entire eye, 
the little tumour being removed with the conjunctiva. Cicatrization readily 
took place, and all pain ceased. Three months after, however, the unfortunate 
woman applied on account of another tumour extending under the orbitar sur- 
face of the lower eyelid. This, too, was extirpated in November, 1849, and the 
wound perfectly cicatrized. 

If the resources of art have not been, in this curious case, as complete as might 
be desired, it cannot be doubted that they have procured for the patient several 
years of tolerable comfort, and have prolonged her life. — British and Foreign 
Medico- Chirurgical Review, from Gazette des Hopitaux, 1849, No. 143. 

36. On Femoral Hernia. — M. Malgaigne has recently published an interest- 
ing series of papers upon femoral hernia, a few passages from which we here 

The differential diagnosis of Femoral and Inguinal Hernia. — Where the track 
of the hernia is distinct, there can be no difficulty in distinguishing between 
these ; but sometimes, though very rarely, cicatrices or bands induce a devia- 
tion of this. Much oftener, in their early stages, the inguinal or femoral 
hernia, separated from each other only by the thickness of the Fallopian (Pou- 
part's) ligament, intrench more or less on this, either on the one side or the 
other, and then the track of the hernia becomes doubtful. It becomes of im- 
portance, therefore, to observe the exact position of the two rings. The femoral 
ring is situated somewhat more externally than the inguinal, and is bounded 
on its outer side by the femoral artery, the pulsations of which are always per- 
ceptible, above by the Fallopian ligament, and below by the pubis. The in- 
guinal ring, in its normal state, is bounded by its two pillars above and below, 
and has no artery on its external side. We find the femoral ring by passing 
the finger along the inner side of the artery, backwards and upwards, until it 
rests on the pubis behind, and is arrested by the Fallopian ligament above. 
The inguinal ring is found by feeling for the spine of the pubis, into which its 
lower pillar is inserted. 

When we have to do with a hernia of doubtful nature, we should return it, 
and observe at which aperture it disappears. Sometimes the return takes place 
too rapidly for this to be remarked, and we should then apply a finger at one of 

1850.] Surgery. 207 

the apertures, while the patient makes an effort to reproduce the hernia. If 
we feel it tend to escape by the one aperture, or it succeeds in doing so by the 
other, all doubt is removed. In this way I have seen the nature of a very diffi- 
cult case decided. A young woman consulted M. Marjolin for a small tumour 
in the groin, which appeared and was returned from time to time. When M. 
Marjolin placed his finger on it, it disappeared so suddenly that he was unable 
to observe its course, and all attempts to cause it to reappear proving unavail- 
ing, he sent the case for my opinion. I know of no example of an inguinal 
hernia refusing to reappear after reduction, except in the case of congenital 
hernia of young subjects ; and as, on making this patient cough, nothing ap- 
peared at the inguinal ring, while a strong impulse was felt at the femoral ring, 
I had no no doubt of its being a femoral hernia. 

When a hernia is irreducible, it may so ride over the Fallopian ligament as 
to prevent this being felt, while the raised' state of the skin prevents the finger 
reaching the rings in a direct manner. More than one operator has discovered 
the true nature of such a hernia, only after the exposure of the neck of the sac. 
If we push down the skin somewhat at the upper and inner part of the tumour, 
we may often reach the spine of the pubis, and judge whether the inguinal 
canal is occupied by a hernia, and the same manoeuvre repeated at the lower 
and middle portion of the hernia allows us to examine the condition of the 
femoral ring. 

Sometimes the inguinal ring is so widened that the finger passed into it feels 
the iliac artery beating on its external side, the relaxed Fallopian ligament al- 
lowing it also to reach the pubis ; so that we have some of the characters of 
the femoral ring present. But the femoral ring never acquires this size, and, 
on exploring the inner side, we arrive directly at the spine of the pubis, while, 
at quite the external extremity, the Fallopian ligament, relaxed as it may be, 
resists the finger, and prevents its reaching the pubis. 

So much for hernia which quit either of the canals ; but ether difficulties 
arise from interstitial hernia. A tumour is observed towards the middle of the 
bend of the groin, but rather nearer the pubis. It is deep-seated and ill-cir- 
cumscribed, projects when the patient coughs, but comes out or goes in with 
such rapidity that its course cannot be followed. The inguinal canal is free, 
but the hernia yet seems to lie in its direction. If we try to follow the course 
of the Fallopian ligament, it is flaccid and felt with difficulty, and seems to be 
situated at about the middle of the tumour, at the level of which it offers no 
appreciable resistance. Lastly, if we draw a straight line from the superior 
iliac spine to that of the pubis, the tumour is found in part or entirely below 
this. In many cases, an exploration of the femoral ring settles the question as 
to which of the rings the hernia issues from ; for if, on the patient's coughing, 
a sharp impulse is felt by the finger placed over this, without any external 
swelling being produced, it is a femoral hernia ; while, if the finger feels no 
such impulse, and a hernia appears above, it is inguinal. But we sometimes 
observe, especially in women whose abdominal parietes have become much dis- 
tended from child-bearing, an inguinal interstitial hernia, that so depresses 
the Fallopian ligament as to transmit an impulse to the finger placed below it ; 
while, on the other hand, a femoral hernia sometimes so raises it as to produce 
a sensible projection above when we close the femoral aperture. In such a 
case, we place the thumb across the inguinal canal, so as absolutely to close the 
internal inguinal ring, and leave the femoral ring quite free. The patient 
coughs, and if the hernia is inguinal, nothing can escape, and the index-finger 
placed below the femoral ring receives no impulse ; but if the hernia is femoral, 
the finger is pushed back by the advancing tumour. 

The Influence of Sex in the production of Femoral Hernia. — After adverting to 
the statements of Morgagni, Sandifort, Scarpa, and others, of the almost com- 
plete exemption of the male sex from femoral hernia, M. Malgaigne observes, 
that, however seldom such cases may present themselves in small hospitals, 
there is no lack of them in the hospitals and dissecting-rooms of Paris. J. 
Cloquet found, that, of 258 hernial tumours situated in the groin in men, 203 
were inguinal and 55 crural, i. e., 1 to 4 ; but, as no other observer has seen 
this proportion, accident may have led to its production in this series of cases. 

208 Progress of the Medical Sciences. [July 

In regard to M. Malgaigne's own experience, lie saw, in October and Novem- 
ber, 1835, at the Bureau Central, 330 male subjects with, hernia of the groin, 
and of these only 14 had femoral hernia, and 9 of these even had, at the same 
time, inguinal hernia. Counting the hernise instead of the subjects, there were 
515 inguinal to 16 femoral (about l-35th). During the five years he remained 
at the Bureau Central, the proportion continued much the same, or rather less. 
As, owing to the small size of femoral hernia, many persons affected by it 
might take it for something else, and, therefore, not apply at the bureau for a 
truss, M. Malgaigne instituted an examination at Bicetre, and there he found 
14 femoral hernise to 90 inguinal (l-6th). This examination was continued by 
M. Roustan, who found, in 1043 hernia cases, 953 inguinal, 22 femoral, and 22 
both femoral and inguinal. Counting the hernise, there were 1335 inguinal to 
65 femoral (l-20th). It is to be observed that the great bulk of these persons 
were above 40 years of age ; and M. Malgaigne, from his general observation 
at different ages, believes the proportion to be 4 or 5 per cent. 

The fact of the greater liability of women to femoral hernia is incontestable ; 
but M. Malgaigne has long opposed the statement that, even in women, more 
femoral than inguinal hernias exist. During his first investigation of the subject, 
in 1835, he found that of 62 women, 53 had inguinal and 8 femoral hernia; 
and, although this enormous disproportion has never been reproduced, yet, with 
the most scrupulous care in the diagnosis, he has never found the number of 
femoral equalling those of inguinal hernise ; and several of his colleagues at the 
Bureau Central, induced by him to reinvestigate the subject, have arrived at 
similar conclusions. In May and June, 1840, 57 women were examined at the 
bureau, and of these 32 had inguinal, 22 femoral, and 3 both femoral and in- 
guinal hernise. Counting the hernioe, there were 47 inguinal to 32 crural. In 
1837, MM. Nivet and Manec stated that, of 116 hernise of the groin occurring 
among the old women at the Salpetriere, 67 were femoral, 40 inguinal, and 9 
of doubtful nature. M. Malgaigne, surprised at this statement, induced M. 
Manec, in 1840, to undertake, with him, a careful reinvestigation. During this, 
93 women were found with hernise of the groin, and these were most carefully 
and repeatedly examined, with the result of showing that 54 had inguinal, 35 
femoral, and 4 both inguinal and femoral hernise. The general result of his 
observations leads him to believe that a third or a fourth more inguinal than 
femoral hernise are met with in women. As illustrative of the fallacy of rely- 
ing upon small numbers, he says that, during his first examination with M. 
Manec, 18 women were presented, 10 having single or double femoral hernia, 
4 inguinal, and 3 femoral and inguinal. At the second visit, 4 women were 
seen, in all of whom the hernise were inguinal. In counting the hernise, the 
first visit furnished 14 femoral and 9 inguinal ; but the second visit brought 
them to an equality. 

Influence of Age. Femoral hernia is essentially an affection of adult life. M. 
Malgaigne has only seen two examples of its occurrence prior to twenty, in 
one of which it was said to have come on during infancy, and in the other was 
produced at eight years during pertussis. Sir A. Cooper has seen cases at the 
respective ages of seven, eleven, and nineteen. M. Nivet states that he has 
seen five such cases, but his diagnosis was probably at fault. It has been ob- 
served in the foetus. This circumstance distinguishes it broadly from inguinal 
hernia ; for, of 135 cases of this observed by M. Malgaigne in women, it occur- 
red prior to the first year in 12, and between the first and twentieth year in 17. 
The age of twenty once reached, the two kinds of hernia seem to be alike in- 
fluenced as regards age. 

Predominance of the right side. In 313 inguinal hernia occurring in men, M. 
Malgaigne found that 171 appeared primarily on the right, 102 on the left, and 
40 simultaneously on both sides. In women, the predominance was slightly on 
the left. Thus, of 133, 51 occurred on the right, 60 on the left, and 22 on both 
sides. J. Cloquet also found 23 on the left to 19 on the right; but he and M. 
Malgaigne are the only observers who have arrived at this result. In femoral 
hernia, the right side predominates. Thus, in 67 women, 36 had it on the right 
side, 25 on the left, and 6 on both sides. 

Secondary Hernia. M. Malgaigne claims the merit of having first pointed 

1850.] Surgery. 209 

out the singular predisposition which inguinal hernia, at least in men, exerts 
in the production of hernia of the opposite side. Thus, in 274 cases of primary 
hernia, secondary hernia had occurred in 144 at the time of examination ; and 
in two-thirds of these the second hernia had become spontaneously developed 
without the person being able to assign any cause. As women resist the origi- 
nal production of hernia more than men, so are they less liable to its secondary 
formation. Of 114 persons suffering from primary inguinal hernia, in 26 only 
were secondary hernise observed ; and of these the lesser number had formed 
spontaneously. Of 12 men suffering from primary femoral hernia, in 6 no 
secondary hernia had yet become induced after from ten to fifteen years. In 3 
of the other six, crural hernia on the other side had followed, and in the other 
3, inguinal hernia. In women, 61 primary crural hernise had been followed by 
9 secondary crural, and 3 secondary inguinal herniee. — British and Foreign 
Medico- Chirurgical Review, April, 1850, from Revue Medico- Chirurgicale, torn. vi. 

37. Cases of Vascular Tumour of the Urethra, with Remarks. By H. B. Nor- 
man, F. R. C. S. — In this pamphlet the author records ten cases of vascular 
tumour in the female urethra, five of which he saw himself, and the others 
being selected from published works. From the consideration of these cases it 
appears — 1st, that no part of the female urethra is exempt from attack ; 2dly, 
that it may vary in size from a simple large granulation to the bulk of a 
turkey's egg, although a small size is far more common than a large one; and 
that, whether sessile or pediculated, they are sensitive in the highest degree ; 
3dly, that in structure they consist of hypertrophied papillae, invested with a 
thick layer of cuticle, and are abundantly supplied with vessels and nerves ; 
4thly, that they are not cancerous ; 5thly, that they tend to reproduction on re- 
moval; 6thly, that they occur in both married and single, and at all ages ; 7thly, 
that sexual abuses and syphilis cannot be shown to originate them ; 8thly, that 
urethral pain, augmented by micturition, coition, walking, &c, suppression of 
urine from dread, or, on the other hand, frequent micturition from vesical irri- 
tation, more or less vaginal discharge, and, occasionally, lumbar, pelvic, and 
femoral pain, with a discharge of blood from the canal, are its ordinary symp- 
toms, rendering the physical examination of the passage to the bladder the 
more important as the symptoms might lead to a suspicion of a calculus in that 
receptacle ; 9thly, that, somehow, this state has been mistaken for prolapsus 
uteri, but that any error of diagnosis can scarcely occur when a visual or tactile 
examination is instituted; as regards the last, Mr. Norman points to the fact, 
which we imagine the profession to be scarcely aware of, that the finger may 
readily be introduced along the meatus urinarius, so as to allow of its entire 
length being investigated, and any morbid growths at the neck of the bladder 
being detected; lOthly, the treatment recommended is removal by ligature 
rather than by excision, touching the spot, after separation of the growth, with 
a powerful cautery, as the potassa fusa ; when small and near the orifice, they 
may be removed by touching with the last named caustic, nitric acid, or the 
pernitrate of mercury, and when they affect the interior of the canal generally, 
bougies are highly serviceable applications. — Provincial Med. and Surg. Journ. 
March 20, 1850. 

38. Rupture of the Urinary Bladder. — Rupture of the bladder is an accident of 
interest not only in a medico-legal, but also in a surgical point of view. In our 
preceding No., p. 383 et seq., will be found an interesting case of this accident 
recorded by Prof. Peaslee, and as a further contribution to the history of this 
injury, we subjoin the following cases recently communicated to the Pathologi- 
cal Society of London (Ap. 1, 1850.) 

In the first case, which was related by Mr. Solly, the rupture was occasioned 
by a blow on the abdomen, the patient not having made water for five hours 
previously. He was admitted into St. Thomas's Hospital seventeen hours after 
the accident. About two quarts of urine were drawn off. 

Post-mortem examination, Feb. 26th, 1 P. M. — Head not examined. Thoracic 
viscera healthy. Abdomen : the peritoneum covering the abdominal viscera 
generally, but more particularly the small intestines, was irregularly congested 

210 Progress of the Medical Sciences. [July 

in patches ; and on the surface of some of the congested portions was a small 
quantity of recent lymph, in thin adherent flakes ; this was more particularly 
seen on the convolutions of the small intestine contained in the pelvic cavity. 
The parietal peritoneum was healthy, with the exception of slight patches of 
congestion. In the peritoneum, over the posterior part of the bladder, was a 
longitudinal rent of an inch and a quarter in length, corresponding to which 
the muscular and mucous coats of the bladder were lacerated to the same ex- 
tent ; so that a catheter readily entered the peritoneal cavity. The peritoneum 
in the immediate neighbourhood of the wound, from half to three-quarters of an 
inch beyond its edges, was coated with a layer of adherent plastic lymph ; the 
membrane was congested for an inch or more beyond the lymph, but there were 
no other indications of peritonitis. The cavity of the peritoneum contained 
from two to three ounces of what appeared to be urine, rendered turbid by the 
admixture of a small quantity of lymph, of which a little floated in the fluid. 
The bladder was firmly contracted. The thick edges of the wound were coated 
with adherent black coagulum. Liver and kidneys healthy. Mr. Solly re- 
marked that in a similar case he should puncture the pelvic cul-de-sac of the 
peritoneum, as recommended by Harrison, of Dublin. 

Mr. Prescott Hewett, in connection with the last case, brought forward ten 
cases of ruptured bladder, which, with one exception, occurred at St. George's 
Hospital within the last few years. 

The first was a specimen of extensive rupture of the apex of the bladder in- 
to the cavity of the peritoneum, from a man, set. 35, who lived two days after 
the accident. On his admission into the hospital, under Mr. Hawkins, a cathe- 
ter was passed, and a large quantity of bloody urine drawn off; he was then in 
a state of collapse, from which he never rallied. The urine, which con- 
tinued to be bloody, was always drawn off without any difficulty. At the post- 
mortem examination, extensive fracture of the pelvis was discovered, and this 
laceration of the bladder, which measured about two inches in length, and an 
inch and a half in breadth. The bladder itself was contracted, and in its cavity 
were some small clots of discoloured blood. No marks of inflammation were 
found in the peritoneal cavity. An ounce only of turbid fluid was dis- 
covered in the cul-de-sac, between the bladder and rectum. The other parts 
were healthy. 

The second specimen was also one of rupture of the bladder into the peritoneal 
cavity taken from a woman, whose husband, in a quarrel, threw her down, and 
knelt upon her abdomen with great force. She immediately became sensible of 
having sustained some severe internal injury, and died twenty-four hours after- 
wards, in excruciating agony. In this case there were two lacerations : one of 
which, about half an inch in length, led into the cavity of the peritoneum ; and 
the other, about two inches in length, into the cellular tissue of the pelvis. 
The preparation is in Mr. Csesar Hawkins's museum. 

The third specimen was one of rupture of the forepart of the bladder, im- 
mediately behind the pubes, caused by a man jumping on the abdomen of the 
patient when he was on the ground : he lived twenty-three days after the acci- 
dent. Mt. 50, he was admitted into the hospital, under Mr. Tatum, two days 
after the injury, with an anxious countenance, and great pain and extension 
over the lower part of the abdomen, accompanied by great difficulty in passing 
his water. A catheter was passed, and a pint of bloody urine drawn off. The ne- 
cessary treatment was adopted, and he appeared to be going on pretty favoura- 
bly for some days, at the end of which time three distinct tumours, presenting evi- 
dent but deep-seated fluctuation, made their appearance : one of these tumours was 
in the mesial line, immediately above the pubes, and the other two in the iliac 
regions. On the twelfth day after his admission, a free incision was made into 
the lower part of the left iliac region, letting out about three ^ints of fetid pus, 
with large sloughs. This was followed by a marked amendment, which lasted 
but a few days. The wound put on an unhealthy appearance, and the urine, 
which had for several days been passed without inconvenience, now flowed 
freely through the wound in the left iliac region. At the post-mortem examina- 
tion, the peritoneum was found extensively stripped off from the parts in the 
neighbourhood of the bladder, as well as from both iliac fossse, and from the 

1850.] Surgery. 211 

walls of the abdomen, as high as the umbilicus. The cellular tissue in these 
various regions was in a sloughy state, and filled with large quantities of foul 
matter. The bladder presented, in its forepart, a rupture of about an inch in 
length and half an inch in breadth, which led into a perfectly circumscribed 
cavity in the surrounding cellular tissue, the walls of which were so thick and 
so well formed that, at first sight, it appeared like one of the sacculi so fre- 
quently met with in this organ. Towards the lower part of this cavity the 
wall of the cyst had, however, become detached from the margins of the rup- 
ture, so that here there was an opening through which the tip of the little finger 
was easily passed into the cavity of the bladder. The bladder itself was very 
much contracted, and its mucous membrane, of a dark colour, was in various 
parts covered with lymph containing a sandy deposit. 

The fourth was also a specimen of rupture of the forepart of the bladder into 
the cellular tissue ; in connection, however, with fracture of the pelvis. The 
patient, set. 12, was admitted, under Mr. Cutler, in a state of collapse, some 
twenty hours after the accident — heavy iron railings having fallen on the lower 
part of the abdomen. No urine having been passed, a catheter was introduced, 
and a small quantity of bloody water was drawn off. The belly became tym- 
panitic, and tension, swelling, and redness made their appearance in the lower 
part of the abdomen, in the scrotum, groins, and upper part of both thighs. 
These symptoms were soon followed by delirium and low fever, and he died 
six days after the accident. At the post-mortem examination, the bladder was 
found to be ruptured in two different places, in its forepart. The margins of 
the ruptures were sloughy, and sufficiently large to allow of the passage of a 
large bougie. Urine had been extensively infiltrated into the cellular tissue of 
the pelvis, and some of it had made its way into the upper part of both thighs, 
scrotum, &c, by passing through the obturator foramina. Large sloughs existed 
in various parts ; the pelvis was extensively fractured, and a small quantity of 
blood was found in the cavity of the peritoneum. 

The fifth specimen was one of rupture of the lateral part of the bladder into 
the cellular tissue, in connection with extensive injury of the pelvis. The pa- 
tient, a middle-aged man, was under Mr. Hawkins, and died twenty-two hours 
after the accident. The laceration, about one inch in length and half an inch 
in width, was situated on the left side of the bladder, and led into the sub- 
peritoneal cellular tissue, where there was extensive effusion of bloody fluid. 
The urine, which was drawn off shortly after the patient's admission, was bloody. 

The sixth case was one of rupture of the neck of the bladder, in connection 
with extensive fracture of the pelvis, from a man, set. 38, who was admitted 
under Mr. Keate, and died five days after the accident. The two anterior thirds of 
the neck of the bladder were completely separated from the prostatic portion of 
the urethra. The cellular tissue of the pelvis, as well as that in the hypogas- 
trium, iliac regions, upper part of both thighs, and right side of the scrotum, 
was in a sloughy state, and infiltrated with pus and urine. The extravasation 
was traced, on the right side, through the internal ring and inguinal canal 
down into the scrotum ; but there was no extravasation towards the perineum. 
The bladder itself was extensively inflamed, its mucous membrane being of a 
dark colour. 

The seventh was a rupture of the bladder in connection with extensive lacera- 
tion of the symphysis pubis. The rupture, which was on the right side of the 
organ, was large enough to admit a good-sized quill; it led into a small per- 
fectly circumscribed cavity, formed in the surrounding cellular tissue, by the 
effusion of lymph. Beyond this adventitious pouch the cellular tissue was ex- 
tensively infiltrated with sanious fluid. A little above this rupture there ex- 
isted appearances which looked like a smaller rupture blocked up by lymph. 
The mucous membrane of the bladder was inflamed, and in patches covered 
with lymph. The patient, aet. 32, was admitted under Mr. Keate, the wheels 
of a chaise, out of which he had fallen, having passed over the lower part of 
the belly, some twelve hours before his admission. The urine which was drawn 
off was bloody ; pain and tension of the belly soon made their appearance, ty- 
phoid symptoms set in rapidly, and he died on the 4th day. 

The eighth was a rupture of the forepart of the bladder, leading into the sub- 

212 Progress of the Medical Sciences. [July 

peritoneal cellular tissue, in connection with extensive injury of the pelvis and 
dislocation of the hip, produced by a piece of timber falling on the patient's 
back. The man set. 32, was admitted under Mr. Hawkins, and lived four days 
after the accident. Shortly after his admission into the hospital, the cellular tissue 
of the scrotum, perineum, and lower part of the abdomen began to swell, and 
then assumed a dark colour. A catheter was passed into the bladder at three 
different times, but no urine was found there. Mr. Hawkins having subse- 
quently introduced a catheter, made a free incision into the urethra, and several 
others also into the inflamed parts, through which urine escaped freely. The 
wounds ultimately took on a sloughy character, and he died in a low muttering 
delirium. Besides extensive fracture of the pelvis, there was a rupture in the 
forepart of the bladder, immediately behind the symphysis pubis, of the size 
of the end of the little finger. Between the bladder and pubes there was a 
large cavity, containing coagulated blood, urine, and pus, the peritoneum being 
stripped off nearly as high as the umbilicus. With the exception of some 
slight adhesions between this part of the serous membrane and the omentum, 
there were no traces of inflammation about the peritoneum. 

The ninth was a rupture of the bladder in its forepart, just below the re- 
flexion of the peritoneum. The laceration was about an inch in length, and 
had given rise to extensive infiltration of urine and blood into the surrounding 
cellular tissue, the peritoneum being stripped off from the wall of the belly as 
high as the umbilicus. The patient, a man set. 46, was admitted under Mr. 
Hawkins, having been kicked by a horse on the lower part of the belly about 
five hours before. The urine which was drawn off was mixed with blood. 
Rigors and great pain in the belly soon supervened, and he died fifty-eight 
hours after the accident. 

The last was also a rupture of the bladder external to the peritoneum, but in 
connection with separation of the symphysis pubis and fracture of the pelvis. 
The bladder was ruptured immediately behind the pubes. The man, set. 34, 
was also under Mr. Hawkins ; he had fallen from a great height, and died two 
hours after his admission into the hospital. 

In the observations on the preceding cases, attention was drawn especially to 
the following points : — In two of these ten cases there was no injury of the 
bones ; in eight, the pelvis was extensively fractured. In two cases the bladder 
was ruptured into the peritoneum (one being with fracture of the pelvis, the 
other without). In eight cases the rupture was into the cellular tissue of the 
pelvis ; in these eight cases the bladder was ruptured in its forepart in five, in 
its lateral parts in two, at its neck in one. 

Both the cases into the peritoneum were most interesting ; the one from its 
rarity, the injury having occurred in a woman, of which there are very few 
cases indeed placed on record ; the other, from there being so small a quantity 
of fluid found in the peritoneum, merely an ounce, and yet the rent in the blad- 
der was large enough to admit of the passage of the two first fingers, as well 
as from there being no trace of inflammatory action about the serous mem- 

The variety of points at which urine extravasated into the sub-peritoneal 
cellular tissue might show itself was also well illustrated in some of these 
cases. In one, the patient living twenty-three days, large abscesses made their 
appearance above the pubes, and in both iliac fossae. In another, in addition 
to these regions, the scrotum and perineum became extensively infiltrated. In 
a third, the right side of the scrotum was the part principally affected, the urine 
having passed through the right internal ring, and down the inguinal canal. 
In a fourth, the upper part of both thighs was affected, the urine having made 
its way through the obturator foramina. 

Lastly, the reparative efforts sometimes made by nature in accidents of this 
kind were also well shown. In a patient who lived five days after the accident, 
the cellular tissue in the immediate neighbourhood was condensed by lymph, 
forming a species of pouch connected with the margins of the rupture. In 
another case, living twenty-three days after the injury, the surrounding cellu- 
lar tissue was so condensed, and so firmly attached to the margins of the rup- 
ture, except at a small point, that the secondary cavity thus formed presented 

1850.] Surgery. 213 

the appearance of a sacculus of the bladder which had given way. With re- 
gard to the point where the lymph was detached, Mr. Hewett thought this ap- 
pearance was due to the tearing off of the false membrane during some efforts 
made by the patient : the history of the case he considered showed this. An 
aggravation of symptoms suddenly takes place, and the urine, which for seve- 
ral days had been passed without inconvenience or effort, now makes its ap- 
pearance in the incision in the iliac fossae, and henceforth flows freely through 
the opening. — London Med. Gaz., April 26, 1850. 

The following very interesting case of this accident is recorded by Mr. W. 
H. Stapleton in the Dublin Quarterly Journ., Feb. 1850. Charles Scarlett, aged 
twenty-two years, unmarried, by occupation a labourer, was admitted into Jer- 
vis-street Hospital on the 30th of September, 1849. 

Whilst working the Panorama at the Kotunda, on Saturday evening, the 
29th inst., being in a state of intoxication, he fell about the height of twelve 
feet from a ladder, and said that he came upon his feet. He was brought to 
the hospital in a car. Upon examination by the resident pupil no injury was 
apparent, nor did he complain of any, with the exception of a small cut on the 
elbow, which being dressed, he was brought home ; and the persons with him 
were directed to bring him next day to the hospital, should he, when sober, find 
that he had suffered any other injury. 

On Sunday, the 30th inst., he walked from his lodgings in Britain street to 
the hospital. On his admission he said that he was in great agony with pain in his 
belly, and that he had passed no water since before the occurrence of the acci- 
dent ; that his stomach had been very sick during the night and morning, hav- 
ing a frequent inclination to vomit and also to evacuate his bowels, neither of 
which was he able to accomplish ; he also complained of great headache and 
thirst. His countenance was pale and anxious; the pulse quick and feeble ; the 
extremities cold. 

The catheter was now introduced, and about two ounces of dark-coloured 
urine mixed with blood drawn off. He was then put to bed, when, on examina- 
tion, the abdomen was found tense and extremely painful on pressure. The 
catheter was again introduced, and a small quantity of clear urine drawn off. 
A laxative enema was prescribed, as his bowels had not been opened for some 
days previously, and also to relieve the tenesmus, which was very troublesome. 
It acted satisfactorily. Twelve leeches were then ordered to be applied over 
the region of the bladder, and the parts to be afterwards fomented : two grains 
of calomel and half a grain of opium to be given every third hour. 

October 1st. —He was seen by Dr. Stapleton for the first time at 9 A. M. He 
was then sitting up in bed, with his chin almost upon his knees, complaining 
of intense pain in his abdomen, which prevented him from lying down. The 
pulse was small and scarcely to be felt, and the extremities cold and blue, al- 
though he was enveloped in blankets, and heaters had been applied to his feet. 
He had refused during the night to allow the application of the fomentations, 
as he said the pain was increased by the slightest pressure. The catheter was 
introduced, and a small quantity of transparent limpid urine drawn off. 
He stated that on getting up to the night-chair (which he had been frequently 
obliged to do on account of the desire he felt to go to stool), he each time passed 
water. Leeches were again ordered to be applied over the region of the blad- 
der, and after their removal the abdomen to be covered with a warm poultice. 
He was to take a grain of calomel and a grain of opium every second hour. 

October 2d. — He was now troubled with diarrhoea. The calomel was omitted, 
and a grain of opium given every second hour, the abdomen fomented with 
warm water and turpentine, and the poultice re-applied after each fomentation. 

In the evening he was under the influence of the opium, and was able to lie 
down and stretch out his legs. The opium to be continued according to the 
effects produced. 

October 3d. — Diarrhoea and tenesmus still urgent. Starch and opium injec- 
tion were prescribed. In the evening, the diarrhoea and tenesmus still continued 
unabated ; he could allow pressure on the abdomen, and, although in a drowsy 
state, complained of want of sleep. Acetate of lead and opium injections were 
now ordered. 

214 Progress of the Medical Sciences. [July 

October 4th. — Diarrhoea and tenesmus still unabated, and the abdomen en- 
larging. Complains greatly of want of sleep, and begs to have opium pills, 
which were given every second hour. 

In the evening hiccough had been added to the other symptoms, and the 
pulse could not be felt in one arm. He was still able to get up to the night-chair 
(obstinately refusing any assistance in bed). A blister to the epigastric region 
was ordered, and a mixture of camphor and sulphuric ether given occasionally. 

October 5th. — Is evidently sinking rapidly, although he speaks with a firm 
voice and is able to get out of bed without assistance. The pulse has failed at 
the wrist. 

The catheter was introduced at intervals, and scarcely an ounce ever came 
away at one time. 

He died at about 3 o'clock, P. M. 

The body, when examined on the morning of the 6th, presented the following 
appearances. The abdomen was tumid, but no sign of ecchymosis was appa- 
rent. On opening the cavity of the peritoneum a large quantity of fluid escaped. 
The intestines were not much distended, but were preternaturally vascular. 
There were a few very slight adhesions, but no gluing together of the intes- 
tines. The liver was nodulated, and presented several old adhesions on its 
anterior surface ; the omentum was very vascular, and lay in a shrivelled mass 
across the upper part of the abdomen, presenting no appearance of lymph on 
either surface. The intestines were easily turned out (there being but few and 
very slight adhesions) from the pelvic cavity, which contained about a pint of 
a turbid fluid, having a strong ammoniacal odour. 

The fluid being removed, the peritoneum was found coated thickly with 
lymph. The bladder did not extend above the pubis. An elastic catheter hav- 
ing been introduced through the urethra, air blown into the bladder was found 
to escape, bubble by bubble, from its upper and posterior part. The lymph be- 
ing removed, a transverse but rather oblique rent was found in the peritoneum 
of about three-quarters of an inch in length, that in the bladder being of greater 
extent ; its edges were jagged, thickened and extremely vascular. There was 
no discolouration of the peritoneum in the neighbourhood of the rectum, but, 
on examination, the surrounding areolar substance was much inflamed. 

From the appearances on dissection it was evident that nature had gone far 
in this case towards the accomplishment of a cure of the ruptured bladder ; 
and I am inclined to think that had the man in the first instance drawn atten- 
tion to the injury received he might have recovered. In similar cases I would 
be disposed to rely more upon the opiate treatment, in combination with leech- 
ing or general blood-letting, than upon the use of mercurials. I would not re- 
commend a catheter to be left in the bladder, but would have it introduced at 
proper intervals, and not farther than was absolutely necessary just to enter 
the bladder. It should be also borne in mind that there is but little secretion of 
urine in acute peritonitis, and, in addition, the constant tenesmus which is al- 
ways present, and might almost be said to be pathognomonic of this accident, 
induces the patient frequently to empty the bladder, although ruptured. In 
the ninth volume of the first series of this Journal there is a very able and valu- 
able paper by Professor Harrison on rupture of the bladder, in which he ad- 
vises tapping of the pelvic cul-de-sac through the rectum. This operation, re- 
commended by so high an authority, has been, as far as I am aware, never yet 
tried, nor would I wish to give a decided opinion against it, yet I cannot avoid 
remarking that the effects of the accident are, in its first moments, insidious, 
and have proceeded to a destructive extent internally before its nature is sus- 
pected by the sufferer. Moreover the operation is not recommended by the 
learned professor " till the cul-de-sac is distended with fluid coated with lymph, 
and well protruded towards the rectum." "When such is the state of the pa- 
tient, I fear the operation will not be followed by the happy result he expects. 

39. Case of Gunshot Wound, and subsequent Extraction of a Bullet from the 
Bladder. By E. M. Macpherson, Assistant-Surgeon 9th Lancers. (Proceed- 
ings of Royal Medical and Chirurgical Society, March 26, 1850.) — A private 
in H. M. 24th Regiment was wounded (at the battle of Chillianwallah, on 

1850.] Surgery. 215 

the 13th of January, 1849) in the left buttock: severe pain was immediately 
felt in the testicle on the same side: the ball could not be found, but the 
wound healed without difficulty: no blood was ever noticed in the urine. 
Symptoms of disturbance of the bladder shortly afterwards set in, which not 
yielding to remedies the bladder was examined, and a foreign body detected ; 
and on the 30th of August the lateral operation, as if for the removal of a cal- 
culus, was performed : an iron ball was extracted, which had become encrusted 
with a thin layer of sandy deposit. To the above case Mr. Dixon added notices 
from various writers of fifteen operations for the extraction of balls, which had 
either primarily entered the bladder, or, having lodged in the immediate neigh- 
bourhood, had made their way into its cavity. Mr. Dixon had been favoured 
by Mr. Cusack, of Dublin, with a notice of a similar operation performed by 
him, and another by the late Mr. Colles, neither of which has been published : 
in three cases extraction was not attempted, or was unsuccessfully tried, the 
bullets, forming nuclei of stones, having been found in the bladder after death ; 
in one case the bullet was small enough to be voided by the urethra. The situa- 
tion of the external wound in the cases cited was very various. The time that 
elapsed between the infliction of the wound and the removal of the ball varied 
from a day or two to ten years. The lateral operation was performed in the 
majority of cases, but the high operation had been employed by Baudens on 
account of the ball having entered at the bottom of the linea alba, so that by 
enlarging the recent wound he could reach the cavity of the bladder. — London 
Med. Gaz. April 5, 1850. 

40. On Dressing Wounds and Ulcers with Charcoal. — In 1846, Dr. Newmann 
recommended the employment of charcoal as a substitute for charpie, plasters, 
ointments, &c. ; and since that time numerous cases ("thousands" in all, he 
says) have confirmed him in the conclusion that the great majority of open sur- 
faces are far more rapidly healed by this means than by any other. 

One great object of applications of any sort is the exclusion of the atmospheric 
air, which coming in contact with the pus decomposes it. The capillary action 
which takes place between the granules of the charcoal prevents a great accu- 
mulation of the pus on the surface of the wound, and spreads it widely, so that 
it dries and fills up the interstices of the powder, and prevents the access of air 
to the wounded surface. Charpie and lint also exert capillary action, but not to 
the same extent, as they cannot penetrate so closely among the irregularities 
and depressions of the wound. Besides this effect, due to its porosity, charcoal 
exerts a most favourable influence by its power over putrefaction, and hence 
its great use in gangrenous wounds, and in fact in all open surfaces when 
changes in the pus are to be feared. In corroboration of this general eulogium, 
the author selects certain special cases, which usually offer some difficulty in 
their management. 

Thus every one knows what a troublesome affection is produced by an in- 
growing nail, and the painful character of the remedies employed ; Dr. New- 
mann declares he is enabled to heal the obstinate ulcer thus produced in as 
many days as these various means require months. Having separated the soft 
parts from the nail, so as to expose the ulcer in its entire depth, he deposits the 
charcoal freely therein, having combined with it a little acetate of lead, or oxide 
of zinc, leaving the entire nail covered with this, and binding a piece of lint over 
it, the patient wearing a wide shoe and keeping quiet. In twenty-four hours 
the toe is bathed in tepid water, and new charcoal is added to the wound, with- 
out disturbing any of that previously applied, which may be firmly adherent. 
A week or a fortnight of such treatment suffices to heal the wound. Sore nipples 
constitute one of the minor ailments that cause great suffering and trouble in 
healing. In this case he usually employs lycopodium mixed with a little oxide 
of zinc (for a fine powder, not charcoal alone, though usually the most prefer- 
able one, constitutes the basis of treatment), with which the part is well pow- 
dered each time the child has sucked. This penetrates into the fissures of the 
nipple, and however strongly the child may suck, some of it remains in contact. 
The wound quickly heals. Discharges from the ear, dependent upon ulceration 
of the meatus, are healed by charcoal in three or four weeks, even if the ulcera- 

216 Progress of the Medical Sciences. [July 

tions were considerable. The meatus is syringed out every day, and the char- 
coal then freely introduced. Fissure of the rectum is one of the most painful 
and distressing diseases that come under the cognizance of the surgeon. The 
charcoal should be applied after every stool, and often in the day besides, care 
being taken to have it effectually and freely brought into contact with the 
fissured surface. Dr. Newmann, after expatiating upon the difficulty of treat- 
ing the suppurating wounds supervening on extensive burns, so as to prevent 
deforming cicatrices, declares that charcoal obviates much of the inconvenience, 
by keeping the surface of the wound dry, even when the suppuration is abun- 
dant ; and that contraction does not follow, or it is much less considerable than 
after any other mode of treatment. If the burn is on the back, the charcoal 
may be freely strewed over the bed. Since he has employed the same means 
in gunshot wounds, he has met with much less trismus and tetanus, and has 
been surprised at the rapidity of the cure. In the treatment of ulcers of the 
legs, even without insisting upon the recumbent posture, he has also been very 
successful. In a few days the surface becomes cleaned, and a good crop of 
granulations developed, while the callous edges are levelled. To diminish the 
circumference of the sore more rapidly, strips of adhesive plaster are now ap- 
plied above and below it, and across its middle, the intervals between the strips 
being strewed with charcoal, covered with ointment spread on lint, and band- 
aged. This dressing is renewed every two or three days. In this way ulcers, 
which have continued open for years, have been healed in six or eight weeks, 
the patient still taking moderate exercise. 

The cheapness of the substance, and the ease with which it may be prepared, 
under a variety of circumstances when ordinary dressings are not obtainable, 
should recommend it strongly, Dr. Newmann observes, to hospital and military 
authorities. — British and Foreign Medico- Chirurgical Review, April, 1850, from 
Casper's Wochenschrift, 1849, Nos. 42 and 43. 

41. On Disjunction of the Lower Epiphysis of the Humerus. By Wm. Smith, 
M. D. [The Dublin Quarterly Journal of Medical Science, Feb., 1850.) — In this 
interesting paper, the author endeavours to demonstrate that fracture of the 
humerus immediately above the condyles has been generally confounded with 
disjunction of the inferior epiphysis of the same bone from writers overlook- 
ing the fact, " that the lower epiphysis of the humerus does not include the condyles, 
which belong entirely to the shaft of the bone." 

" The lower articular surface of the humerus in the young skeleton," Dr. Smith 
remarks, " differs from that of the adult bone in the following remarkable par- 
ticular, namely, that the capitulum, or that portion which articulates with the 
head of the radius, is nearly double the size of the trochlea ; so that the infe- 
rior surface of the former is nearly upon the same level as that of the latter 
process ; and the humerus, when placed resting by its lower extremity upon a 
horizontal plane, assumes nearly a vertical position : in short, the radial is fully 
developed long before the ulnar portion of the epiphysis, and, as will hereafter 
appear, the knowledge of this fact is not destitute of practical importance in 
the diagnosis of that embarrassing accident, fracture through the line of junc- 
tion of the epiphysis with the shaft, or, in other words, fracture of the humerus 
immediately below the condyles." 

A description of the signs which characterize this lesion must also be, to a 
certain extent, an enumeration of those which accompany dislocation of both 
bones of the forearm backward ; many of the symptoms likewise belong to 
the transverse fracture, immediately above the condyles. 

The injury usually results from a fall upon the elbow, but I have known it 
to occur from a fall upon the palm of the hand, the forearm being at the time 
extended upon the arm. The limb immediately becomes powerless, severe pain 
is experienced in the elbow, and the following signs present themselves : — The 
forearm is flexed, and the hand in a middle position between supination and 
pronation. The olecranon, drawn upwards and backwards by the triceps 
muscle, mounts above the level of the condyles of the humerus, these three 
processes forming the points of a triangle, the base of which is below. The 
antero-posterior diameter of the elbow is greatly increased, and the lower end 

1850.] Surgery. 217 

of the humerus can be felt projecting in front. The application of a gentle 
force is usually sufficient to restore the normal appearances of the limb, but 
when the parts are abandoned to themselves the deformity soon recurs. If, 
after the removal of the displacement by extension, the forearm be rotated 
upon the humerus, or if the surgeon, as recommended by Dupuytren, grasps 
the arm in one hand, and the forearm in the other, and then moves them back- 
wards and forwards upon each other, the crepitus which characterizes fracture 
can generally be elicited. The motions of flexion and extension are exceedingly 
limited, and any attempt upon the part of the surgeon to communicate them 
produces severe pain. 

The signs above enumerated are sufficient to demonstrate that the injury in 
question may readily be confounded with transverse fracture of the humerus 
above the condyles, or with luxation of the forearm backwards. The former 
would be a mistake of comparatively slight importance, inasmuch as the same 
treatment is applicable to both lesions ; but the latter must be considered as a 
grievous error, the results of which are nearly as lamentable as those of leaving 
a true luxation of the joint unreduced. The observations of Dupuytren re- 
specting the danger of confounding fracture immediately above the elbow with 
dislocation backwards, apply with peculiar force to the injury we are con- 

"If," says this distinguished surgeon, "the opinion that the case is one of 
luxation be acted upon, extension and counter-extension are employed, the 
reduction is accomplished without much difficulty, a roller is applied, and the 
surgeon congratulates himself upon the ease with which he has restored the 
bones to their places. But soon the displacement is reproduced, and at the 
end of a few days, in the midst of the swelling, something unnatural is felt. 
This accident is generally ascribed to the patient, who is charged with being 
intractable: the reduction is again effected, but the deformity soon recurs, and 
considerable swelling then supervenes. As long as this condition lasts, the 
surgeon continues secure ; but when the swelling has disappeared, after the 
lapse of a few weeks, he discovers the error which he has committed, but the 
mischief cannot now be repaired, the motions of the joint are never perfectly 
regained, and the deformity is incurable." 

As the loss of the normal relation between the olecranon and the condyles 
renders the separation of the epiphysis peculiarly liable to be confounded with 
dislocation of the forearm backwards, and as it is obviously a matter of the 
utmost importance to distinguish carefully between these accidents, let us now 
consider the signs, by availing ourselves of which we materially diminish the 
chance of mistaking it either for luxation, or for fracture above the condyles. 

In case of fracture traversing the line of the epiphysis, the transvere diame- 
ter of the tumour which projects in front is equal to that of the opposite hu- 
merus, measured anteriorly from condyle to condyle ; in this respect the accident 
resembles the dislocation of both bones backwards, but differs from fracture 
above the condyles. The outline of this osseous tumour is rounded, presents to 
the feel none of the irregularities or sharpness of an ordinary fracture, and upon 
its inferior surface, which is convex, and limited at either extremity by the 
condyles, neither trochlea nor capitulum can be distinguished. 

When the joint is viewed posteriorly, two osseous prominences are seen, and 
can be distinctly felt ; they are both placed above and behind the plane of the 
condyles, but are themselves situated (if the patient be not more than six or 
eight years of age) nearly upon the same level, the internal, however, being 
always a little higher up than the external. At a more advanced age the dis- 
tance between these two prominences is observed to be greater, in consequence 
of the increased development of the internal, which is formed by the olecranon, 
the summit of which process grows by an epiphysis. 

At no period of life, however, at which it is possible for the accident in 
question to happen, is the distance between the two projections nearly as great 
as it is always found to be between those which, in cases of luxation of both 
bones of the forearm backwards, constitute so marked a feature of the injury. 
In the latter accident the distance averages about one inch and a half, while in 
the former it is seldom more than three-quarters of an inch ; the external tu- 

218 Progress of the Medical Sciences. [July 

mour, in this case, being formed by the capitulum of the humerus, still sur- 
mounting the head of the radius, for which, in consequence of the concave form 
of its superior surface, it is extremely liable to be mistaken, if attention be not 
paid to the diagnostic sign which has just been mentioned. 

For the history of the following case I am indebted to my friend, Dr. James 
S. Hughes, one of the surgeons of Jervis Street Hospital : — 

Michael Fleet, get. 12, was admitted into Jervis Street Hospital on the 24th 
of August, 1847. He stated that while standing in the fruit market, a boy, 
running against him with great violence, threw him down, and that having, 
in the act of falling, stretched out his arm to save himself, the other boy fell 
with all his weight across the back of the extended limb. On his being raised 
from the ground, it was found that his arm was powerless, and he was at once 
brought to the hospital, where he was seen by Dr. Hughes, in twenty minutes 
after the occurrence of the accident, and consequently before the characteristic 
features of the injury had become obscured by swelling. 

The forearm was semiflexed, and the hand in the position of half supination ; 
the olecranon, which formed a remarkable projection, was placed above and 
behind the condyles of the humerus. A second osseous tumour, the upper 
surface of which was concave, and which was supposed at first to be the head 
of the radius, could be distinguished behind the outer condyle. The lower 
extremity of the humerus formed a considerable prominence in front. 

Judging from these appearances, Dr. Hughes' first impression was that he 
had to deal with a case of dislocation of both bones of the forearm backwards ; 
but finding that the joint admitted of a much greater amount of flexion than 
can usually be communicated to it in such cases, he began to suspect the exist- 
ence of a fracture. Extension was, therefore, made by an assistant, while Dr. 
Hughes grasping the arm with one hand and the forearm with the other, 
moved them in opposite directions, and thus succeeded in producing a distinct 
crepitus. The diagnosis was therefore made, that the injury consisted in a 
fracture of the humerus through the line of junction of the epiphysis with the 
shaft, with displacement of the bones of the forearm, along with the epiphysis, 
upwards and backwards. 

A moderate degree of extension and counter-extension was sufficient to re- 
move the deformity : the limb was placed in the semiflexed position, and secured 
by angular splints and a roller. It was, however, found extremely difficult to 
prevent a recurrence of the deformity, and when the patient left the hospital 
a slight degree of displacement still existed. Shortly after his dismissal I saw 
him, in consultation with Dr. Hughes and Dr. Powers, and having made a very 
accurate examination of the limb, I came to the conclusion that the original 
injury had consisted in a simple disjunction of the epiphysis ; for although the 
deformity was now not considerable, the principal characteristic features of 
this lesion, as they have been described in the preceding pages, could still be 
recognized. The boy had recovered very considerable use of the limb ; he was 
able to extend the forearm perfectly, and could flex it beyond a right angle. 
The antero-posterior diameter of the joint was greater than that of the opposite 
side; the tendon of the triceps was in relief; the outline of the tumour which 
projected in front was rounded; but it was impossible to feel distinctly either 
the capitulum or the trochlea of the humerus. Two osseous tumours, formed 
by the olecranon and the capitulum, were seen posteriorly ; but although they 
were still situated somewhat behind the plane, they were not now above the 
level of the condyles. The callus which had been effused, obscured, in some 
degree, the features of the injury. About this time the patient was also seen 
by Mr. Adams, who adopted the same views as to the nature of the accident. 

From what has been stated in the preceding pages, it is manifest that (con- 
trary to what the statement of authors would lead us to infer) implicit reliance 
is not to be placed upon the loss of the normal relation between the olecranon 
and the condyles of the humerus, as a means of distinguishing between luxa- 
tion of the forearm backwards, and fracture of the lower extremity of the 
humerus. It is evident that there is an accident of the elbow, in which the 
bones of the forearm lose their natural relations to the condyles, and yet that 
accident is not necessarily a dislocation, but may be a fracture through the 

1850.] Surgery. 219 

line of the lower epiphysis of the humerus, which line is situated below the 

The importance of being familiar with the anatomy of the epiphyses of the 
long bones need not, therefore, be again alluded to ; I may, however, be per- 
mitted to remark that it is also a matter of practical advantage to be acquainted 
with the periods at which the different epiphyses unite with the shafts of the 
bones to which they belong ; for instance, the lower epiphysis of the humerus 
becomes identified with the shaft long before the superior : the separation of 
the latter by external violence may, therefore, occur at a period of life when the 
disjunction of the former would be impossible. 

I shall terminate this brief notice of fracture through the line of the lower 
epiphysis of the humerus, by stating as concisely as possible the points of 
resemblance and dissimilarity between it and the two injuries with which it is 
most liable to be confounded, viz., fracture immediately above the condyles, and 
luxation of both bones of the forearm backwards. 

The symptoms which belong to it, in common with fracture above the condyles, 
are the following: — Shortening, crepitus, the removal of the deformity by ex- 
tension, and its tendency to recur when the extending force is relaxed, the 
presence of an osseous tumour in front of the joint, the increase in the antero- 
posterior diameter of the elbow. 

It differs from the supra-condyloid fracture in the greater transverse breadth 
and regular convex outline of the anterior tumour ; in the existence of two 
tumours posteriorly ; in the loss of the normal relation of the olecranon to the 

It resembles dislocation of both bones of the forearm backwards, in the fol- 
lowing particulars : — 

The transverse diameter of the anterior tumour is the same in each case ; so 
also is the antero-posterior breadth of the elbow ; and in both the olecranon 
ascends above the condyles, the limb is shortened, and two osseous prominen- 
ces can be distinguished posteriorly. 

It differs, however, from luxation in the existence of crepitus, the tendency 
of the deformity to recur, in the anterior tumour being destitute of trochlea 
and capitulum, and in the circumstance of the two posterior tumours being 
nearly upon the same level. 

42. Perpendicular fall from a height of 192 feet — Fracture of the thigh and 
patella, with severe concussion of the thoracic viscera — perfect recovery. — The fol- 
lowing extraordinary case is recorded by Dr. Knox, surgeon to the Strangford 
Dispensary, in the Dublin Medical Press, May 8th, 1850 : — 

"On the 8th of September, 1834, Alexander Boyd, of the coast guard service, 
under the command of the late Captain Gilbert, K.N., whilst patrolling on the 
cliffs which overhang the sea, in the vicinity of Kenbawn-head, near Bally- 
castle, in the county Antrim, mistook his way, owing to the extreme darkness 
of the night, and fell over a precipice, rising sheer from the seamark, as I after- 
wards ascertained by measurement, to the height of 192 feet. In his descent 
he grazed slightly the face of the cliff at one point only, about 93 feet from the 
summit, and fell on a slip of grass land lying between the base of the cliff and 
the sea. Here he lay for some hours, until a little dog, the companion of his 
walks, gave the alarm by whining at the door of his cottage, and caused a 
search to be instituted along the coast. The circumstances of his almost mi- 
raculous escape attracted so much attention at the time, that the place where 
this extraordinary accident occurred was visited by great numbers of persons 
for many week afterwards. 

When called to see him on the following day, I found that the femur had 
been fractured obliquely at the superior portion of the middle third, and the 
patella of the same side, longitudinally. Slight abrasion of the cuticle of the 
leg and the outer ankle were observed, and the thigh and knee were greatly 
swollen. He complained of severe pain at the upper part of the sternum, and 
in the course of the splenii muscles, as well as of much dyspnoea, aggravated 
by deep inspiration. The pulse was 100, and the respirations 24 in the minute, 

220 Progress of the Medical Sciences. [July 

the skin hot, the tongue white, and the bowels costive. His mind was appre- 
hensive but unclouded, and no injury of the head was apparent. 

As the injured limb was both very painful and much swollen, I at once de- 
termined not to attempt immediate reduction of the fractures, but to trust to 
secondary coaptation or setting, after the inflammatory symptoms should have 
subsided, and contenting myself, in the meantime, with placing the limb in the 
position most easy for the patient, and supporting it by cushions properly 
adapted to prevent motion of the broken extremities of the femur. A cold spi- 
rituous lotion was directed to be applied with great regularity ; the most perfect 
quiet and very low regimen were enjoined; a full dose of castor oil was admi- 
nistered; and on account of the injury of the chest, which obviously presented 
the chief source of danger, thirty ounces of blood were detracted from the arm. 

Sept. 10th. The symptoms were little changed. An additional purgative was 
necessary, and calomel and antimony were prescribed, in small doses, three 
times a-day. 

lliA. The medicines have acted powerfully; the pain of the chest and diffi- 
culty of breathing are much abated ; the swelling of the limb remains undi- 
minished, but he complains of no pain in it except on motion; pulse 80; respi- 
ration 16. 

12th. Griping and tenesmus having occurred, the mercury was suspended, 
and a draught, containing castor-oil and laudanum, relieved the abdominal 
irritation. On the 15th the pectoral symptoms were completely removed, and 
the swelling and inflammation consequent on the fractures sufficiently abated 
to admit of the application of a laced cap to the knee, and of the necessary 
bandages and splints to the thigh. The limb, when the fracture was reduced, 
was apparently of the same length as the other. Regular action of the bowels 
was promoted by the occasional use of aperients, and the patient was allowed 
a more generous regimen. 

On the 22d, the apparatus having become somewhat disarranged, was cau- 
tiously removed, and the limb being found in its proper position, it was again 
carefully and firmly adjusted. The pulse 70, the bowels regular, and the appe- 
tite good. Animal food was now allowed. 

On the 26th, considerable pain in the course of the thigh being complained 
of, the bandages were slackened a little, and an aperient administered. On the 
5th of October, and again on the 13th, the splints were slightly re-adjusted, and 
the bandages tightened. On the following day, sharp pain at the site of the 
femoral fracture annoyed the patient considerably, but he received instant 
relief by the division of one or two turns of the bandage. On the 29th of 
October the entire apparatus was removed, when both fractures were found to 
be consolidated ; the limb apparently unshortened, but with imperfect power of 
motion, the muscles appearing paralyzed by long pressure and want of use. 
The knee also was somewhat stiff, and painful on flexion being used. The re- 
peated application of a stimulant embrocation was therefore directed, and care- 
ful passive motion of the affected joint, the entire limb being swathed in new 

Nov. 2d. The patient was permitted to leave his bed, his health being excel- 
lent, and the power of using the injured limb gradually increasing. By the 
middle of the month he could move about with the aid of crutches ; and on the 
8th of December, exactly two months after the accident, the only symptom 
which remained was a degree of stiffness of the knee-joint, preventing the full 
use of the limb. This gradually abated, and in a short time he was enabled to 
rejoin the coast guard service, and to patrol as usual for several years after- 
wards. I have lost sight of him lately, but I believe he is still in the service. 

The chief points of interest in the above case are the successful result of se- 
condary setting of the fracture, and the very extraordinary escape of the patient 
from immediate death, as I have never heard of a similar case, nor should I 
have believed in the possibility of a fall, from a height of 200 feet, occurring 
without certainly fatal results. Once, indeed, in the harbor of Malta, I was an 
eye-witness of the fall of a seaman from the truck of a line of battle-ship, per- 
haps 176 feet ; but in that case, the man fell in the water, having only glanced 
against the chains in his descent, by which, however, the os femoris was frac- 

1850.] Surgery. 221 

tured in two places. He was, I believe, uninjured in other respects, as he swam 
until picked up, and rejoined his ship in a few weeks, after cure of his fractures 
in the Malta Naval Hospital. 

The other point, which is of more practical importance, was the treatment 
of the fracture of the thigh by delaying the application of the permanent appa- 
ratus until the inflammatory symptoms had in a great measure subsided, 
applying only, in the first instance, such support, by means of position, folded 
sheets and cushions tied round the limb with sufficient firmness to prevent 
injury of the soft parts by displacement of the injured extremities of the bone. 
This mode of treating fractures I learned from Sir. S. L. Hammick, now of 
London, when I was serving as assistant-surgeon in the Royal Naval Hospital 
at Stonehouse, Plymouth, and observation of what I had an opportunity of see- 
ing in his practice, and subsequently in my own, justifies me in forming a most 
favourable opinion of the plan advocated by that very distinguished surgeon in 
his truly ' Practical Remarks/ where the reader may find the comparative 
merits of primary and secondary fractures ably discussed. The frequent occur- 
rence of shortening in oblique fractures of the femur, even when most carefully 
treated, is known to all surgeons, and it has even been stated on high authority 
that this is inevitable ; but a result so unfavourable has not occurred in the ex- 
perience of the eminent surgeon alluded to, and the cases treated by him, under 
my observation, by secondary setting were perfectly successful. This very day, 
by a singular coincidence, I have had an opportunity of examining accurately 
a fracture treated by him, in the person of a pensioner of marines, which oc- 
curred about forty years ago. 

The cure was most perfect, not the slighest difference being perceptible either 
in the dimensions or (as I am assured by the patient), in the sensations, or 
motive power of the affected side. 

Without entering here into a discussion of the comparative merits of primary 
and a secondary setting of fractured bones, I shall content myself with stating 
that I have found the latter mode of treatment perfectly successful in several 
cases. But if only equally successful in the results with the plan of immediate 
reduction almost universally recommended, there appear to be several reasons 
which entitle it to a preference, of which the risk of severe and dangerous 
inflammation is one of the principal, and the consequent necessity for removing 
the apparatus perhaps more than once. No doubt cases occur in which the 
immediate application of splints is indispensable, as on board ship in rough 
weather, or where the patient is furious from delirium or intoxication ; but 
under favourable circumstances, I believe any surgeon, who shall judiciously try 
the mode of treatment here advocated, and which is very minutely described 
in the work alluded to, will find that it shall not disappoint his expectations. 
It may be said, however, as the swelling and inflammation were too far ad- 
vanced, before the patient was seen, to admit of primary co-aptation of the 
fracture, that the case detailed is scarcely in point. The following instance, how- 
ever, is : A strong muscular labourer was struck by the end of an enormous log 
of wood, which fractured the middle third of the os femoris obliquely. As the 
man was so circumstanced that I could have him closely under observation, I 
contented myself with flexing the thigh on the great trochanter, and flexing 
the leg to such an extent as rendered the position most easy to the feelings of 
the patient, and with taking such general measures as the nature of the case 
required, for preventing displacement of the bone, and moderating the inflam- 
mation. When this was abated about the tenth day, I placed the patient on 
his back, reduced the fracture accurately, and applied very firmly the necessary 
bandages and two splints along the inner and outer aspect of the thigh, suf- 
ficiently long to secure the heads of the bone. A third splint, but shorter, so 
as not to press on the patella, was placed in front. The whole apparatus was 
firmly secured by strong tapes, and beyond occasionally tightening, or slightly 
readjusting it, nothing further was requisite. 

The bone was perfectly consolidated by the ninth week, the callus having 
been thrown out rapidly and abundantly. In ten weeks the patient was per- 
mitted to move about with crutches, and he very rapidly regained the full 
power of the limb. There was no apparent shortening, nor the slightest halt 
No. XXXIX.— July, 1850. 15 

222 Progress of the Medical Sciences. [July 

perceptible. Now, I would not assert that an equally perfect consolidation 
might not have been effected in the ordinary mode of immediate setting, but a 
better one certainly could not, and if only attended with an equal degree of 
success as to the final result, the mode in question appears to have, as I have 
already stated, some important advantages. Where it shall be adopted, it ap- 
pears to me that the starch bandaging of Seutin may be employed with much 
greater safety than when used immediately after the receipt of the injury." 

43. Ligature of the Subclavian Artery for Aneurism. By James Stme, Esq. — 
Mr. EL, a mercantile gentleman, about fifty years of age, in the course of last sum- 
mer, while travelling by railway, was thrown with great force to the opposite 
side of the carriage, in consequence of the train being suddenly stopped, and 
struck the forepart of his right shoulder on one of the partitions between the 
seats. He did not sustain much inconvenience from this injury at the time, 
but before long began to suffer from pain in the neighbourhood of the injured 
part, which, being ascribed to rheumatism, was treated by leeching, fomenta- 
tions, and friction. Having experienced no relief from the use of these means, 
he applied to Dr. Begbie, who examined the shoulder, and finding a pulsating 
tumour below the clavicle, proposed that I should see the case. 

The tumour occupied the hollow on the inner side of the shoulder, and lay 
under the pectoral muscle, close up to the clavicle, but did not ascend above 
the bone. It ceased to pulsate when the subclavian artery was compressed, 
which could not be effected without considerable care and much force, from the 
neck being remarkably thick. The patient possessed a robust frame, with an 
apparently very energetic temperament ; but so far as we could ascertain, did 
not labour under any other disease than that for which our assistance was re- 
quired. He stated that there was nearly constant uneasiness proceeding from 
it, and occasionally paroxysms of agony greater than he could endure. In 
these circumstances we felt no hesitation in recommending that the artery 
should be tied without any delay, except what might be requisite for moderat- 
ing the force and frequency of circulation. With this view, he was confined 
to the house for a few days in bed, on a restricted diet, and under the action 
of moderate laxatives. 

On the 23d of October, in the presence of Dr. Begbie, and with the assistance 
of Dr. Richard Mackenzie, I performed the operation. The patient lay on a 
table, with his head towards the window — an arrangement which, after trying 
different methods, I consider by far the most convenient ; and the incisions 
were made as usual, one extending along the clavicle, while another proceeded 
nearly from its centre at a right angle, in an upward direction, parallel with 
the external edge of the sterno-mastoid muscle. The external jugular vein, 
which lay much in the way, being retained in its position by a large cross 
branch, was cut across, and tied at both orifices. A pretty large mass of fat 
and lymphatic glands, occupying the triangular space under the platysma 
myoides, was dissected out, so as to facilitate access to the artery, which was 
then readily exposed, and tied by a single silk thread. 

Next morning Dr. Begbie and I were urgently summoned to see the patient, 
who had been extremely restless during the night, insisting upon getting out 
of bed, and exciting great alarm, by cold sweats, fainting, and other unpleasant 
symptoms. We found him much more comfortable than he had been; and, on 
the whole, in a satisfactory state, with the exception of a very frequent pulse, 
which was about 120. After this everything went on favourably, the pulse 
gradually subsiding in the course of ten days or a fortnight to the natural 
standard. The wound healed kindly, and the ligature separated on the twenty- 
third day, but recovery was then delayed by a slight attack of erysipelas. The 
patient is now, and has been for some time past, perfectly well, without any 
perceptible trace of the aneurism. 

The points of interest in this case seem to be — 1. The mode of production 
by a blow, which could act only by bruising, and not by extending the coats of 
the vessel; 2. The division of the jugular vein without any bad consequence, 
which tends to recommend this as the proper course when the vessel does not 
admit of being readily held aside, as happened, and led to the same procedure, 

1850.] Surgery. 223 

on the only occasion that Mr. Liston tied the subclavian artery with success ; 
and 3. The alarming symptoms which occurred during the night after the opera- 
tion, and would certainly have been attributed to the influence of chloroform, 
if any had been administered to the patient. 

I have now operated upon five cases of axillary aneurism, three by ligature 
of the subclavian, and two by amputation at the shoulder-joint. Four of the 
patients are alive and well ; in the fifth the artery was very much diseased, as 
might have been suspected from the fact that I had formerly operated upon 
the patient for popliteal aneurism, and as was positively ascertained after 
death, at the end of a fortnight from the operation, in consequence of hemor- 
rhage. In a sixth case, I commenced the operation, but desisted from proceed- 
ing with it as the tumour was found to ascend too high for the safe application 
of a ligature. Electro-puncture was afterwards tried without any good effect. 

With regard to the general question respecting the treatment of aneurism, 
it may be added that I have tied the femoral artery eighteen times without any 
bad effect from the operation. In sixteen of these cases there was either a 
popliteal or femoral aneurism. Fifteen were cured, and the sixteenth, after 
appearing to be so, ultimately proved fatal through suppuration of the tumour. 
I have also operated in eleven cases of brachial aneurism, with complete suc- 
cess in all of them. The strenuous efforts of some surgeons in Dublin to revive 
pressure as a substitute for ligature has led to trials of this plan in Edinburgh. 
But I am not aware of its having proved successful, even in a single instance. 
— Monthly Journal of Medical Science, March, 1850. 

44. Paracentesis Thoracis. — Dr. George F. Easton read before the Liverpool 
Medical and Pathological Society, Feb. 21, 1850, the following interesting case, 
in which paracentesis thoracis was performed: — ■ 

James Galium, aged 26, of temperate habits. His father, and a brother and 
sister, have all died of affections of the chest, probably phthisis, though this 
cannot be accurately ascertained. His mother is still alive, at the age of 80, 
and he has two brothers and a sister. 

He had good health till the month of May last, when he had a smart attack 
of fever, accompanied with bronchitis, which lasted about a fortnight. He re- 
sumed his occupation too soon afterwards, in an open shop ; but, as his cough 
did not get much, if at all worse, the inconvenience it occasioned was too tri- 
fling to induce him to desist from work. By and by, his breathing became 
affected; but the difficulty of respiration was so gradual in its progress, and the 
symptoms of pleuritic disease so insidious, that its true cause, for a long time, 
escaped detection. About the beginning of September it was discovered to 
result from an accumulation of fluid on the right side of the chest. About the 
middle of the month it had risen as high as the nipple : and, notwithstanding 
the use of medicine, its progress was unrestrained, till, at the commencement 
of October, it had reached the clavicle. He was kept for some time under the 
influence of mercury. Blistering and other remedies were employed ; but, 
after remaining in a hospital nearly three weeks, he left without experiencing 
any benefit. 

As no prospect remained of the fluid being removed by absorption ; as the 
prolonged use of medicine, which had no apparent control over the disease, 
was more calculated to do harm than good, by still further deranging his gene- 
ral heath ; as the dyspnoea was great, and no success could be expected from 
an operation performed at a much later period, on account of his obviously 
declining strength, it was resolved to undertake it without delay. To the ordi- 
nary symptoms of fluid in the pleura there was superadded another, indicative 
of the complication of the disease with pneumothorax ; an audible fluctuation 
produced when the patient was shaken, by the splashing of the fluid against 
the walls of the chest. 

A consideration of the uniformly fatal issue of those cases in which this 
unfavourable symptom owes its origin, as it usually does, to the bursting of a 
tuberculous abscess into the pleura, led me to propose the operation rather as 
a means of relief than as affording any very encouraging prospect of ultimate 
recovery. Profuse nocturnal sweats, from which he suffered, made me some- 

224 Progress of the Medical Sciences. [July 

what suspicious that this might be the source of the contained air ; but, as I 
had failed to detect the presence of tubercles in either lung, I felt greatly dis- 
posed to view it in a more favourable light, as the effect of secretion. 

There were two or three other reasons which assisted me in thus regarding 

1st. Its very trifling amount, as ascertained by percussion, any resonance 
which existed being confined to a small spot that could be covered with two 
fingers, and which varied with the patient's position. 

2d. The absence of hgemoptysis and purulent expectoration. 

3d. The entire absence of appreciable pain during the course of the disease. 

I think we might reasonably expect, if a vomica had discharged its contents 
into the pleura, that its rupture would have occasioned an amount of pain 
sufficiently severe to mark the commencement of the inflammation which gave 
rise to the subsequent effusion; but no such pain was ever complained of, and 
the patient repeatedly told me that he had never experienced any, even of the 
slightest description. 

The patient, at the time of the operation, had bronchitis in the left lung. 

On Saturday, November 3d, in the presence of Dr. Turnbull and Mr. Hig- 
ginson, who kindly assisted me, a trocar was introduced into the right side of 
the chest above the eighth rib, and rather more than half a pint of pus re- 
moved. In attempting to adapt an apparatus to prevent the admission of air, 
the canula was partially withdrawn ; and, as it could not be readily reintro- 
duced, we were satisfied for the present with the information which was thus 
derived and the relief which was thus afforded. No bad symptom followed. 
A blister was applied to the affected side, and some cod-liver oil, with a bitter 
infusion containing iodide of potassium, was ordered to be taken daily, preceded 
on the first occasion by a purgative. 

At the end of a week, the dimensions of the chest having undergone no 
change since the operation, and the other physical signs of the disease remain- 
ing as before, the operation was repeated, and eight pints of the same inodor- 
ous purulent fluid were slowly withdrawn. This was accomplished without 
producing any material effect on the patient, except a disagreeable feeling 
which arose about the middle of the operation, and increased towards its termi- 
nation, resulting from the removal of pressure to which the displaced viscera 
had become accustomed, and from the necessity occasioned by the collapsed 
condition of the right lung for their rather sudden movement in an opposite 
direction, to supply the vacant space caused by the abstraction of so much fluid. 
This lasted during the four succeeding days, and was accompanied by inability 
to lie on the affected side, on which he had formerly reposed with greater 
comfort, and by his experience as if any considerable pressure would have 
been attended with danger to the integrity of the ribs. 

The entrance of air into the chest was effectually prevented by the use of an 
apparatus suggested by Mr. Higginson,* which, on account of its simple con- 
struction, its easy management, and its complete efficacy in this instance, I 
can recommend for employment on similar occasions, in preference to others of 
a more costly and complicated nature. It is simply a tube about a yard long, 
made of vulcanized india rubber, which being filled with water, and one of its 
extremities placed over the mouth of the canula, acts on the principle of a 
syphon. If it is properly adjusted, and the other extremity immersed in the 
fluid, air cannot by any possibility gain admission into the chest. The stream 
was free, uniform, and continuous, unaffected by the respiratory movement. 
To the middle of the tube was adapted an india rubber bottle, which in this 
operation does not appear to be essential to success, when the fluid is mode- 
rately thin. When emptied by pressure, and then allowed to expand, it may 
be advantageously employed to clear the tube, if the passage happens to be 
obstructed by lymph or coagulum, or other small bodies of a soft and yielding 
nature, or to wash out the chest with water, or any of the lotions which have 
been recommended for the purpose. And these seem to be the chief, if not the 
only advantageous uses to which it can be applied. 

* Mr. Higginson's apparatus is described in the Lancet, Feb. 27, 1847, p. 240, as a 
simple form of stomach-pump, without valves or stopcocks. 

1850.] Surgery. 225 

It is generally stated by writers that when the operation of paracentesis is 
performed at a stage of the disease when the lung is incapable of expanding, 
that the operator has a choice of but two alternatives. He must either be con- 
tent with the amount of fluid he is able to withdraw from the chest before the 
stream becomes interrupted (which is often only a small proportion of what is 
left behind), or he must obtain a further supply at the expense of replacing it 
by atmospheric air, with the generally experienced consequences of renewed 
inflammation, increased and more offensive secretion, irritative fever, and too 
often rapid and irremediable prostration. Neither alternative is desirable: the 
former on account of the necessity imposed for a frequent repetition of the 
operation, the latter on account of the reasons already assigned. By the use 
of this simple apparatus both are avoided: the fluid may be almost entirely, if 
not wholly withdrawn; the sound lung is placed in the most favourable position 
for increased dilatation, and the condensed one gradually to regain its dimen- 
sions and recover its functions. 

When the tube is filled, and its extremities placed in the positions I have 
indicated, its cavity is continuous with that of the chest, of which it may be 
made to form the most dependent part. The void uninterruptedly formed by 
the escape of the fluid at the lowest part of the tube is communicated upwards 
to the chest, where it will gradually increase, till the last remaining portion of 
the fluid has found its way by gravitation into the tube. 

The patient sat during the greater portion of time that was occupied in the 
withdrawal of the fluid, and towards the close was lowered into the recumbent 
posture to favour its escape by placing the opening in a more dependent 

The trocar used on this occasion was of the size generally -employed in the 
operation for hydrocele. A gentle flow in this case was especially called for to 
prevent laceration of important structures within the chest, in consequence of 
there being no substitution (as in ordinary cases) of atmospheric pressure for 
that of the fluid withdrawn. For this reason, too, the patient was directed to 
breathe with ease, and warned to make no sudden or vigorous effort, which 
might at all subject him to the danger we have specified — a danger great in 
proportion to the amount of effusion. 

The circumference of the chest, before the operation, was three feet one inch 
and a half; the measurement of the right side exceeding that of the left imme- 
diately below the nipple by an inch and three-quarters, and at its most promi- 
nent part by two inches. The operation had the effect of reducing the entire 
circumference two inches and a half — i. e., to two feet eleven inches, the right 
side still preserving an increase over the left of about half an inch, which was 
probably to be ascribed to its naturally larger capacity. By examining the 
respective measurements of the two sides before and after the operation, which 
stand thus — 

Right side, 19x inches > t> r *i 

Left do. 17* « ^ Before the operation, 

Right side, 17f inches \ ., , „ pration 
Left do. 17* « J Alter the operation, 

it will be seen that the affected side measured two inches, and the sound side 
half an inch less after the operation than before it. This diminution of size on 
the sound side can be accounted for only in two ways. We must either suppose 
that the accumulation of fluid on the right side had by its pressure been caus- 
ing distension, and permanent elevation of the ribs on the opposite side, or we 
must explain it by saying that the walls of the chest on the left side were to 
that extent depressed after the operation, in following the organs they con- 
tained in their endeavours to supply the vacancy caused on the right. The 
former opinion I think is scarcely tenable, and therefore I take the latter to be 
the true explanation. 

The patient had no unfavourable or uneasy symptom with the exception of 
that formerly mentioned, which subsided on the fourth day. On the 11th of 
the month (the day after the operation) he resumed the use of his medicine as 
formerly prescribed. On the 13th, his tongue being furred from partaking too 

226 Progress of the Medical Sciences. [July 

freely of animal food on the previous evening, he was ordered a purgative and 
five grains of a combination of blue pill and hyoscyamus each evening at bed- 
time. He was further directed to discontinue the use -of the bitter infusion, 
for which, on the 14th, sulphuric acid was substituted as a tonic. 

At the end of a week he moved about through the house, and walked up and 
down stairs with ease. He slept on either side comfortably and soundly, and 
breathed with increasing freedom. In addition to a nourishing diet, which he 
partook of with a relish, he was then allowed a pint of porter daily. His cough 
had greatly diminished ; and though the sound emitted on percussing the af- 
fected side could scarcely be said to have improved, with the exception of over 
the sternum and a trifle beyond it (which was then naturally clear), yet the 
ribs were slightly raised, and respiration of a bronchial character was heard 
over a large extent of surface both before and behind. 

Thus he continued to improve in health, strength, and appearance, till the 
middle of the fifth week after the last operation, when a marked change was ob- 
served in his appearance. The weather at this time was very unfavourable, so 
that he had seldom been able to go outside the door. He had, moreover, been 
unable to procure employment in the house, so that his days had been spent in 
a state of inactivity, for which we then thought his diet had probably proved 
too stimulating. 

But, whatever cause may be assigned for the relapse, it was evident that the 
matter was again forming. His tongue was deeply furred, his appetite had left 
him, he had frequent attacks of pyrosis, and there was tenderness on pressure 
over the intercostal spaces on the affected side. Recourse was had to purga- 
tives and several counter-irritant applications — such as blisters, nitro-muriatic 
acid lotion, and concentrated tincture of iodine. Calomel and opium were 
given to affect the gums ; but all without avail. The disease made steady pro- 
gress ; the vomitings occurred in the mornings, the tongue remained foul, sleep 
deserted him, the appetite did not return, the cough was greatly aggravated, the 
dimensions of the affected side gradually increased, and the patient became 
more and more emaciated. 

Nor is it likely that these alarming symptoms would ever have received a 
check had not the operation been timely repeated. On the 22d December, six 
and a half pints of purulent fluid were withdrawn in the same way as formerly 
mentioned. It differed from that previously removed in being of a reddish- 
brown colour, and quite inodorous. When this quantity had been removed, the 
patient complained that the canula was causing pain. Attempts were made to 
place it in an easier position ; but, instead of relieving the pain, they had the 
effect of so much increasing it that, neglecting the means of obtaining a fur- 
ther supply of matter we had formerly employed with advantage (viz., that of 
laying the patient down to make the opening more dependent), the canula was 
withdrawn. By this omission a little fluid was left behind; and, by a little 
want of care either in adjusting or withdrawing the tube, a small quantity of 
air must have entered the chest, so as to render again audible the sound of 
splashing, which had not been heard since the performance of the first opera- 
tion. That the quantity was small was evident, as well from percussion as from 
the patient's experience of the same feeling I formerly mentioned after this as 
the previous operation, though not to the same extent, or of so long continu- 

The two sides of the chest afterwards measured alike. 

A favourable change in every respect immediately followed the operation. 
His sleep and appetite returned the same clay, and the vomiting at once ceased. 
In two days the tongue was perfectly clean, and the cough greatly relieved. 

The improvement, however, was of short duration. At the end of a fortnight 
the vomiting and other unfavourable symptoms returned. The vomiting was so 
severe as to return nearly every hour, as much as a quart of acid water being 
sometimes ejected at 4 a time, and was particularly troublesome at night. 

On this occasion I could assign no outward cause for the relapse, as the pa- 
tient had avoided all stimulants, had never left his room, and had been almost 
entirely confined to bed. This circumstance, coupled with an observation that 
the constitutional disturbance was quickly followed by an enlargement of the 

1850.] Surgery. 227 

affected side, led me to this conclusion — that the operation in a case so far ad- 
vanced as the present one, whatever other benefit it may confer, has no effect 
in checking the further progress of the disease, and that the formation of pus 
proceeds without materially affecting the constitution until it does so after a 
considerable accumulation, by causing injurious pressure on the nerves and 
neighbouring organs. 

If this be the case, then the disease is quite of a local character, not likely 
to yield to constitutional remedies, and may co-exist and advance for a certain 
time (as, I think, on both these occasions it has done) with constitutional im- 
provement. The shorter duration of the improvement on the latter than on 
the former occasion is probably attributable to the more rapid accumulation of 
the matter, partly in consequence of its less complete removal, and partly owing 
to the admission of air, which, by altering the character of the secretion, may 
have proved an additional source of irritation. 

If this view of the case be the correct one, then it is obvious that a cure 
could not be obtained by the plan hitherto pursued, and could only be hoped 
for by keeping the secreting sack always nearly empty, with a view to its gradual 
contraction and ultimate obliteration. 

Accordingly, the plan I formed was to remove the whole of the matter, wash 
out the right side of the chest with warm water, substitute a little clean water 
for a portion of the matter (as likely to prove less irritating), to keep off the 
feeling of constriction, and then leaving the plugged canula in the chest to draw 
off a certain portion of it and the secreted fluid at short intervals ; supporting 
the patient in the meantime by a nutritive diet. 

This was put into execution on Tuesday, the 22d of January. That the 
process of washing might proceed with facility and expedition, it was thought 
advisable to use something larger than the small canula hitherto employed, 
and of a material less liable to be acted upon by the secreted fluid. For this 
purpose a gutta-percha tube was formed, and for its admission an incision was 
made into the chest with a bistoury. It was easily introduced, and we were 
fortunate in having made it of sufficient size. At first the matter did not flow, 
and we were beginning to think there must be some mistake, when out it 
poured of a sudden, nearly as thick as treacle, of a sickly offensive odour, and 
of a somewhat darker colour than formerly. With the assistance of the syphon, 
about three pints streamed forth. The stream becoming interrupted, some 
warm water was thrown in to dilute it. It again flowed freely, and we calcu- 
lated that about two pints more of matter were thus removed, independent of 
the water with which it was mixed. Two or three injections of warm water 
were used, and it was our intention to have continued them until the water 
returned nearly colourless. After injecting the fourth quantity, only a small 
portion of it could be got back, in consequence of the large flakes of lymph, 
which we suppose the water had stirred up from the bottom of the chest. The 
tube was plugged and secured in the opening. He complained that it gave him 
pain ; but as it was not severe it was left in its place. 

On the following day, however, we learnt that the pain in the wound had 
become so severe that it had been the cause of his passing a sleepless night. 
The tube was easily withdrawn, and a smaller one of a different shape substi- 
tuted without pain in its place. By the aid of the syphon, between two and 
three pints of fluid then came away, consisting of matter mixed with the water 
left behind on the previous day. Some warm water was then injected, but the 
same difficulty presented itself we had formerly experienced. We could not 
get the whole of it back. Accordingly the canula was plugged, but the patient 
shortly afterwards complained that it was causing pain, which soon became 
excessive. After vain attempts to give him relief by partially withdrawing it, 
the pain became so intolerable that he earnestly entreated me to remove the 
tube. This I was very unwilling to do, but coldness spreading over the body, 
and a shivering coming on, I was afraid of his falling into a faint, from which 
it might be difficult to recover him, and I complied with his request. Air im- 
mediately rushed into the chest, and he experienced instant relief. The cause 
of the pain appears to have been, not the tube but the unequal pressure pro- 

228 Progress of the Medical Sciences. [July 

duced by the exhausting apparatus. A poultice was applied to the wound. 
He soon afterwards fell asleep, and on awaking partook of a hearty dinner. 

On the morning of the 24th, we found that tenderness at the seat of the wound 
during the night had prevented him from enjoying a full amount of rest; 
nevertheless, he appeared better. His pulse was 104 ; his appetite good, and 
his tongue much cleaner. Some opiate pills were ordered to procure sleep. 
The tube was reintroduced, but on withdrawing the plug a little fetid air only 
escaped. It has since remained in the chest, and for about a fortnight a pint 
of pus was daily discharged ; at first partly through the tube and partly by its 
side, latterly through the tube alone. From that time to the present the dis- 
charge has lessened to about one-half. For a few days after the air was ad- 
mitted freely into the chest, the discharge was extremely offensive ; but since 
the air has been again in a great measure excluded, it has lost much of its 
disagreeable odour. 

On the 25th, the third day after the operation, the tongue was perfectly clean. 
As illustrative of the effect of the operation on his digestive organs, I may 
mention, that on that day he ate for breakfast two eggs and three slices of 
bread. At noon he had another slice of bread and a glass of wine. At four, 
nearly a pound of mutton, with a proportionate amount of bread and potatoes, 
and a pint of water ; and in the evening more bread with his tea. His appetite 
has continued equally good up to the present time. 

After a fortnight the porter began to act on his bowels, and the diarrhoea, 
which lasted three or four days before I was informed of it, greatly retarded 
his progress. His pulse is now a little below 100, his breathing 25, and his 
strength, which was very much impaired at the time of the last operation, has 
somewhat increased, notwithstanding the exhausting effect of the discharge 
and the diarrhoea combined. He usually sits up for three or four hours every 
day. Nevertheless it must not be concealed that he is very much emaciated, 
and that any unlooked-for addition to the debilitating agents already at work 
would place his life in immediate jeopardy. I have good expectation, however, 
that his strength will increase more rapidly in proportion as the discharge be- 
comes diminished, and that the constitutional improvement will prove more 
permanent than before, in consequence of the different organs being exempt 
from that injurious pressure, which I am satisfied was the cause of relapse on 
the two last occasions. 

If it proceed, we may hope that while the walls of the right side of the chest 
collapse over the diminished volume of their contents, that the lung will at the 
same time at least partially unfold itself, the air gradually penetrate its sub- 
stance, and absorbtion go forward in any bands of lymph which may oppose 
its expansion. It is probably too much to expect that this will take place to 
any great extent, or that the lung will ever with much efficacy perform its im- 
portant functions. Nevertheless, what nature is unable to effect on the one 
side, she will compensate for on the other, and an irreparable injury done to 
the right lung may be counterbalanced by a fuller development of the left. 
Thus, after a while, the system at large may not be much a loser. 

This, however, will require time, and ere it be accomplished the patient's 
strength may be found inadequate to the long-continued demand upon it, or 
some new disease may arise, or some incipient one be matured, to interrupt 
the work, and thwart this desirable end. I am far, however, from regarding 
the success of the operation as at all dependent on the patient's future progress. 
We have some reason to expect an ultimately favourable termination (and such 
a termination, doubtless, would greatly enhance the value of the means mainly 
instrumental in bringing it about) ; but should it be otherwise, the great ad- 
vantage already derived will amply repay us for our trouble, be more than an 
equivalent to the patient for the trifling suffering by which the benefit was se- 
cured, and fully establish the propriety of the operation. 

The case appears to me to be chiefly interesting — 

1st. On account of the large amount of effusion. The quantity discharged 
at one time was a gallon, and the whole hitherto cannot be much under five. 

2d. On account of its complication with pneumothorax, of doubtful con- 
nection with phthisis. 

1850.] Surgery. 229 

3d. On account of the exceeding mildness of all the symptoms which accompa- 
nied the early formation of the matter, constituting what has been termed the 
latent form of the disease. 

4th. As showing the local character of the disease, and the entire depend- 
ence of severe constitutional disturbance on the pressure of the fluid, and con- 
sequently the inutility of attempting by mere medicinal agents either to cure 
the one or to allay the other. 

Lastly. As exemplifying the facility with which, and the extent to which the 
removal of the fluid may be effected without the admission of air (a matter of 
much importance in more recent cases where the lung is capable of expanding), 
and the great and immediate, and possibly permanent benefit which sometimes 
follows an operation when performed under circumstances apparently very 

Dr. Turnbull read a long list of cases of paracentesis thoracis, of which 
nearly two-thirds recovered and lived for years. 

Dr. Macnaught mentioned the case of a man, aged 35 years, who wore a 
canula constantly, and daily discharged a large quantity of highly offensive 
matter. About every tenth day he had severe dyspnoea, which was relieved by 
injecting warm water. He had known the patient for at least four years ; and 
for anything that he knew he may be alive still, though it is many years since 
he saw him. He rode daily on horseback, and begot several children after being 

Mr. Higginson advocated the early removal of the fluid, if it could be ascer- 
tained to be purulent. In a case of serous empyema the patient had been 
tapped and died. 

Dr. Nevins had seen two cases of serous empyema tapped in London with 
temporary, and only temporary benefit. He had tapped a patient lately two or 
three times, withdrawing about two pints of serum, the first time with manifest 
relief of the urgent symptoms, but the latter tappings produced less benefit, 
and the patient died at last. In a case reported to him by Mr. Hensley, of 
Bath, the patient entirely recovered. 

Dr. Imlach saw a case in which a large quantity of pus was evacuated, but 
on a second operation only frothy blood. After some weeks the man coughed 
up a large quantity of blood, and recovered. 

Dr. Nottingham denied the danger of admitting air, and said abscesses often 
heal best after being freely opened — therefore open the chest freely. — London 
Med. Gazette, April 5, 1850. 

45. Successful Amputation at Hip-Joint. By R. B. Wigstrom, Esq., Lahore. — 
The patient, aged eighteen years, was admitted into the Civil Hospital, at 
Lahore, on the 1st of November, 1849. The disease requiring the operation 
commenced, eight years previously, in the ankle-joint of the right leg. Caries 
of the bones of the leg, and abscesses, gradually went on, until the knee became 
involved, and finally the femur. 

When Mr. Wigstrom saw him the limb was greatly emaciated, and fistulous 
openings, pouring out pus to within a short distance of the hip-joint. The 
young man seemed suffering much from hectic, but there was no cough or any 
symptoms showing lung-disease. In consultation with Dr. Stewart, surgeon to 
the 14th Dragoons, and Dr. Hathaway, civil surgeon, it was considered necessary 
to remove the limb at the hip-joint, which Mr. Wigstrom did, on the 7th of No- 
vember. The operation, which was performed under the influence of chloro- 
form, was finished in half a minute ; the flaps met beautifully together. The 
patient has had a good recovery, and is now going about on crutches. 

The method used was Liston's — i. e., the anterior and posterior flaps opera- 
tion. Not more than two ounces of blood were lost. — Lancet, April 6, 1850. 

46. On Lithotomy and Lifhotrity : Being an Account of the Experience of MM. 
Pamard, Sen. and Jun.,from 1792 to 1849. — The following is the substance of 
a paper (Revne Me'dico- Chirurgicale, May, 1849), by M. Pamard, Surgeon to the 
Hospitals of Avignon, in which he describes all the cases of lithotomy and 

230 Progress of the Medical Sciences. [July 

lithotrity which had come under himself and his father. Documents of this 
description are as valuable as they are rare. 

I am one of those who attach great value to authentic and well-compiled 
medical and surgical statistics. In furnishing such contributions to science, 
country practitioners possess an advantage. Their practice is daily open to the 
observation of their brethren, who live, like themselves, in the midst of the 
patients, and exercise such a check as to render it very difficult for errors, 
either voluntary or involuntary, to occur. I proceed to give the operations of 
my father ; giving first the cases upon whom lithotomy was performed more 
than once, and then those who died within two months after the operation. 
The other cases are arranged according to their date. From the 5th May, 1792, 
to the 19th May, 1818, my father performed lithotomy in sixty cases, of which 
he lost five ; but the sixty operations only represent fifty-five patients, because 
one was cut thrice, and two were cut twice. 

Case 1. V. Duclos, of Pont- Saint-E sprit (Gard), aged 68, was cut in the year 
vii. (A. D. 1798), by an operator of Grenoble. On the 30 Fruct., year vin. 
(1798), my father operated for the first time. A stone again formed, and was 
removed on the 5 Vend, of the year x. (1800), and a third stone was re- 
moved on the 1st Yend. of the year xn. (1802). The patient survived a long 
time after the third operation, without another stone forming. 

Case 2. A. J. Jouve, aged 48, of Gordes (Vaucluse), was cut for stone, on the 
13 Floreal, year vi. (1796). A fistula formed, which probably was the cause of 
the production of a new calculus, for which a second successful operation was 
performed on the 15 Frimaire, year vn. (1797). 

Case 3. J. Ricard, of Cavillon (Vaucluse), aged 15, was cut the first time on 
the 8 Frimaire, year vin. (1798) ; and the second operation, which was suc- 
cessful, was not performed till the 27th September, 1811. 

Case 4. J. Lombard, of Avignon, was cut for stone on the 23 Brumaire, year 
vn. (1797), having had the same operation performed, when 4 years old, by my 
grandfather. The stone never formed after the second operation. 

Case 5. J. Veyren, aged 19, of Villeneuve (Gard), had lithotomy performed 
on the 4 Floreal, year vin. (1798). My father conjectured that the first opera- 
tor had left fragments of the calculus in the bladder. The operation was re- 
peated on the 3 Frimaire, year ix. (1799), and the patient recovered. 

Case 6. T. Morgan, of Caumont (Vaucluse), a female, aged 8 years, had 
suffered from her birth. Lithotomy was performed on the 30 Vendemiaire, 
year in. (1793). The operation was difficult, and the bladder was torn at its 
fundus. The stone was very large, considering the age of the patient, weighing 
105 grammes (about 27 drachms apoth. weight). The child died on the fifth 
day after the operation. 

Case 7. N., a man, aged 72, of Avignon, was cut on the 20th August, 1792. 
He had suffered for 20 years, and was only driven by pain to submit to the 
operation. The pubic artery was probably involved ; the stone was very large 
and jagged. After a succession of hemorrhagic attacks, the patient died on 
the 26th September. 

Case 8. J. O., a boy, aged 10, of Crillon (Vaucluse), was cut for stone on the 
8 Floreal, year vi. (1796). Owing to the size of the stone, the operation was 
long and painful. It broke under the pressure of the forceps, which necessi- 
tated their repeated introduction. Death, from inflammation of the bladder, 
ensued three days after the operation. 

Case 9. F. C, a lad, aged 19, of Malaucene (Vaucluse), was cut on the 23 
Brumaire, year vn. (1797). The operation was easily and rapidly performed; 
but the patient died from phlebitis on the eighth day. 

Case 10. M. V., a man, aged 25, was cut on the 16 Floreal, year vin. ; and 
though there was no complication in the operation, it was followed by death 
from phlebitis on the 27th of the same month. 

Case 11. P., a boy, had a small stone removed by lithotomy, on the 5th May, 
1792. Rapid recovery. 

Case 12. V., male, aged 17, cut 19th April, 1797. Rapid recovery. 

Case 13. M., aged 47, a man, was cut 18th May, 1793. Rapid recovery. 

Case 14. Fabre, aged 8 years, cut 9th May, 1793. Recovery. 

1850.] Swrgery. 231 

Case 15. F., a boy, aged 4 years, cut 27th September, 1793. Kapid recovery. 

Case 16. R., a boy, aged 7 years, cut 21st September, 1793. Recovery. 

Case 17. M., a boy, aged 10 years, cut 7th October, 1793. Hemorrhage oc- 
curred, requiring a canula, armed with agaric, to be introduced ; but, neverthe- 
less, a rapid recovery ensued. 

Case 18. P., a boy, aged 3 years and 8 months, cut 9th October, 1793 ; stone 
small ; recovery rapid. 

Case 19. T., a boy, aged 17, cut 4th January, 1794. Recovery. 

Case 20. T., a boy, aged 12, cut 2d May, 1795. Rapid recovery. 

Case 21. F., a young lad, cut 2d May, 1795. Rapid recovery. 

Case 22. R., a boy, aged 7, cut 2d June, 1795. The stone was fractured ; 
the operation was protracted, and recovery took two months. 

Case 23. R., a man, aged 80, cut 27th May, 1796. He had hemorrhage, re- 
quiring the introduction of a canula. Recovery. 

Case 24. G., a man, aged 24, cut on the 3 Brumaire, year vn. (1797). Re- 

Case 25. R., a boy, aged 5, cut 16 Frimaire, year vn. (1797). The stone 
was large, and the seizing and extracting of it were difficult. Recovery. 

Case 26. A., a boy, aged 5J years, cut 16 Floreal, year vn. (1797). Recovery. 

Case 27. R., a man, aged 75, enormous stone extracted by lithotomy on 10 
Floreal, year viii. (1798). Recovery. 

Case 28. L., a man, aged 47, cut 3 Fructidor, year viii. ; the stone was enor- 
mous. Recovery took place, but with a recto-vesical fistula, evidently origi- 
nating in a wound of the rectum. 

Case 29. A., a boy, aged 9 years, cut 5 Floreal, year viii. (1798). Speedy 

Case 30. R., a boy, aged 9 years, cut 6 Frimaire, year x. (1800) ; two small 
calculi. Speedy recovery. 

Case 31. G., a boy, aged 5 years, cut 20 Floreal, year x. (1800). Recovery. 

Case 32. B., a boy, aged 4 years, cut 24 Floreal, year xi. (1801) ; mulberry 
calculus. Rapid recovery. 

Case 33. B., a boy, aged 8, cut 9 Thermidor, year xn. (1802). Recovery. 

Case 34. D., a young lad, cut 2 Messidor, year xn. (1802). Recovery. 

Case 35. G., a boy, aged 4J, cut 27 Brumaire, year xn. (1802). Recovery. 

Case 36. C, aged 27, cut 3 Floreal, year xiii. (1803). The calculus was large 
and friable ; the operation was prolonged. Recovery. 

Case 37. D., a boy, aged 13, cut 21 Floreal, year xiii. (1803). Recovery. 

Case 38. D., a doctor in surgery, aged 65 ; he had suffered for twenty years, 
but had never allowed himself to be sounded. Pain, at last, overcame his re- 
luctance, and he was cut for stone on the 15th March, 1806. The stone was 
very large ; but nothing untoward occurred, and recovery was rapid. 

Case 39. S., a man, aged 22, cut 3d June, 1806. Recovery. 

Case 40. C, a boy, aged 11, cut 13th September, 1806. Speedy recovery. 

Case 41. R., a man, aged 31, cut 6th December, 1806. From the large size 
of the stone, force had to be used in the extraction ; nothing untoward occurred. 

Case 42. T., a boy, aged 8, cut 24th October, 1806. The stone was large and 
friable ; the child had suffered from his birth ; the operation was prolonged : 
recovery took place, but there was a urinary fistula. 

Case 43. Servant, the curate of Tulette (Drome), aged 68 years, was cut on 
the 9th May, 1808 ; he was a lusty subject, and the operation was laborious ; 
but the success of the operation was complete — a fact worth notice, as Roux, 
the famous operator of the Hotel Dieu, states that every ecclesiastic whom he 
has cut for stone has died. 

Case 44. S., aged 56 years, cut 2d of September, 1810 ; large stone. Re- 

Case 45. T., a man, aged 74, cut 3d of October, 1810. The stone was very 
large, and weighed 110 grammes (about 28J drachms apoth. weight). In spite 
of the age of the patient, and the force required in extraction, recovery was 
quick and complete. 

Case 46. F., a man, aged 50, cut 15th October, 1810. Recovery. 

232 Progress of the Medical Sciences. [July 

Case 47. C, a man, aged 22, cut, 4th October, 1810. Stone large. Recovery. 

Case 48. Madame Valentin, of Avignon, aged 25, cut 7th October, 1811. The 
stone was very large, and its extraction was difficult. The incision, which was 
low, and on the left, involved the vagina. Recovery took place, but she had 
incontinence of urine. 

Case 49. Madame Cambon, aged 21, operated on in the same way as Madame 
V., on 10th November, 1812. She recovered, and had no remaining inconve- 

Case 50. P., a boy, aged 12, cut 24th September, 1812. Recovery. 

Case 51. Melin, aged 3 J, lithotomy 17th May, 1814; small calculus. Speedy 

Case 52. Reynaud, aged 64, large calculus extracted 12th May, 1817 : con- 
siderable hemorrhage. Recovery. 

Case 53. Joussaud, cut 16th June, 1817. Recovery. 

Case 54. Jeaume, suffered from birth, cut 14th June, 1817. From the num- 
ber of calculi, the operation was laborious. Recovery in ten weeks. 

Case 55. M., a woman, aged 58, cut 10th June, 1817. Very large stone. 
Complete recovery. 

Case 56. R., a man, aged 17, cut 19th May, 1818. Success complete. 

I now proceed to detail my own experience ; Jirst, in lithotomy ; second, in 
lithotomy preceded by attempts at lithotrity ; and, lastly, in cases in which 
lithotrity alone was performed. 

Lithotomy. Case 1. M. Baldy, of Nimes, aged 15, had, when six years 
old, been cut for stone, by M. Pleindoux. Till within two years, he had re- 
tained a fistula in perinseo ; operated on. 2d March, 1832. Dismissed cured on 
the 8th April. 

Case 2. M. Martin, of Avignon, aged 20, had suffered from infancy ; but nei- 
ther her pain nor the entreaties of her relatives could induce her to submit to 
an operation. The operation was ultimately performed on the 18th of January, 
1837, under the disadvantageous circumstances of a presentiment on the part 
of the patient that she would not recover. Lithotrity appearing inadmissible 
from the large size of the stone, and the very irritable state of the urethra. 
The stone weighed 77 grammes. For the first days, the patient appeared to be 
doing well ; but, on the fourth, rigors and fever set in, and she died upon the 
24th of January. On dissection, I found the mucous tunic of the bladder red 
and soft ; there was pus in the iliac veins. The abdomen was distended with 
gas, and the peritoneum dotted with red spots. 

Case 3. B., of Monteux (Vaucluse), aged 9 years, was operated upon, at his 
father's house, on the 21st of September, 1836. The stone weighed 10 grammes. 
Recovery was complete fourteen days after the operation ; and the patient, who 
is now a military officer, has never had any return of the affection. 

Case 4. M. C, aged 72, of Entrechaux (Vaucluse), a healthy olfl. man, after 
suffering for four years, was operated upon on the 11th May, 1840. I removed 
three calculi, smooth, and presenting facets formed by friction against each 
other, and weighing, collectively, 80 grammes. The cure was complete on the 
28th June. 

Case 5. L., aged 21, of Fresney (Mayenne), who had suffered from his ear- 
liest years, was operated upon in hospital, on the 10th of January, 1841. The 
stone was bulky and indented, and weighed 45 grammes : it broke under the 
forceps, but was all removed, and the patient was dismissed cured on the 5th of 

Case 6. M., a soldier, aged 27, of Bourret (Tarn-et-Garronne), was operated 
upon on the 18th of January, 1842, in hospital. The stone was hard, volumi- 
nous, and brown in colour; weighed 60 grammes, and was extracted entire. 
The wound showed an indisposition to heal, which rendered it necessary to in- 
troduce deeply the solid nitrate of silver. On the 17th of May, being four 
months after the operation, he went out completely cured. 

Case 7. M., aged 15, of Villeneuve (Gard), a thin and irritable youth, had 
suffered from his earliest recollection ; but his parents could never persuade 
him to allow himself to be sounded, till I was permitted to do this, and dis- 
covered a hard calculus with unequal surface. The extremely sensitive condi- 

1850.] Surgery. 233 

tion of the urethra rendered lithotrity inadmissible, and I performed lithotomy 
on the 20th of February, 1844. The stone was very large, and very light, not 
weighing more than 8 grammes. On the 22d of March the patient left the 
hospital, perfectly cured. 

Case 8. N., a man, aged 27, of Labastal (Hautes-Pyren6es), had endured a 
miserable existence for a long time previous to his entering the hospital, on the 
28th of February, 1845. I cut him on the 2d of March. The case presented 
a circumstance worthy of being mentioned. There was contraction of the 
bladder to such an extent as to impede the separation of the blades of the for- 
ceps. The stone, however, was seized and extracted ; it weighed 32 grammes. 
Its appearance might have suggested the idea that it was a substance moulded 
in the bladder of a child. On its upper part there was a plane surface ; but, 
upon digital exploration, I satisfied myself that there was not a second stone. 
The patient left the hospital cured, on the 11th of April. 

Case 9. G., aged 4J years, of Graveson (Bouches-du-Rhone), had suffered 
from the time of his lactation. I performed lithotomy on the 22d of July, 1847, 
as, in young children, I infinitely prefer this operation to lithotrity. He was 
placed under the full anaesthetic influence of ether. I used polypi forceps, 
being an instrument which I prefer in children. I removed an oval calculus, 
of the size of a large bean ; after which, I introduced my finger (as I always 
do in children), and discovered a second calculus, of the size of a pea, which 
was easily extracted by means of the index finger, without the aid of any in- 
strument. The two stones, collectively, weighed 3 grammes. On examining the 
second calculus with care, it was found to be covered with facets, which led me 
to conclude that these were a group of small calculi ; but, on again introducing 
the index finger, I found the bladder completely unembarrassed. The only 
explanation which can be given of these facets is to suppose that friction took 
place between the two calculi. The issue of this case was fortunate. At the 
end of a month, the child was well ; and, though thin, he was in good health. I 
have seen him this winter, and can testify that he is a superb child, and in the 
enjoyment of perfect health. 

Lithotomy 'preceded by attempts at Lithotrity. Case 10. A. B., of Avig- 
non, aged 8 years, was brought into hospital on the 27th March, 1845. I de- 
tected a small calculus in the bladder ; and, yielding to the wishes of the 
parents, though in opposition to my own opinion, consented to perform litho- 
trity. Having dilated the urethra, I introduced Charriere's modification of 
Heurteloup's lithotrite. I seized the calculus, and broke off a pretty large 
fragment, which was voided into the bath in which I placed the patient imme- 
diately after operating. The operation was quickly performed ; but the rest- 
lessness of the patient induced such severe pain that I thought it my duty at 
once to propose lithotomy, as offering less inconvenience than lithotrity. I 
performed the operation on the 18th of April, and it was followed by quick 

If we may judge from the complaints of the patient, he would seem to have 
suffered less from the operation of lithotomy than from lithotrity, although the 
calculus had been readily seized and broken. The calculus extracted from the 
bladder weighed 5 grammes; and the piece broken off by the lithotrite 1 
gramme and 50 centigrammes. 

Case 11. Mademoiselle P. M., aged 17 years, of Angles (Gard),had been the 
subject of calculus for some years, the existence of which she concealed for a 
considerable time. Her family attendant having discovered its presence, ad- 
vised lithotrity, and she was placed under my care. On the 10th of May, 1847, 
I operated on her at Angles, in the presence of Drs. Salomon, senior and junior, 
Dr. Touzet, and others. The patient having been placed under the influence 
of ether, I easily introduced a No. 3 lithotrite, and immediately found a large 
calculus. The instrument was opened in the bladder with some difficulty ; 
the calculus was broken at three attempts. The patient experienced no pain 
whatever ; and, when she awoke, said she thought she was at church with her 
father. She was placed in a bath immediately after the operation, where she 
voided some fragments of the calculus ; she also voided some fragments, and a 
large quantity of detritus, during the night. 

234 Progress of tlie Medical Sciences. [July 

The operation was twice repeated, at intervals of a few days ; but we found 
that the calculus still remained large. The patient experienced pretty severe 
pain in passing the larger fragments; and on the last two occasions of operating, 
she suffered severe pain, and was very restless ; she refused to be etherized. 
Considering it imprudent to continue lithotrity, we proposed that lithotomy 
should be performed. This was accordingly done on the 25th of June, 1847. 
We adopted the method improperly attributed to Dubois, but which, according 
to Pare, belongs to Laurent Collot, a surgeon of the sixteenth century. The 
incision was made directly upwards, with the lithotome of Friar Come. As 
the calculus had been broken in several pieces, we had to introduce the forceps 
several times. The largest fragment measured 4 centimetres in its greatest 
diameter. The fragment which had been passed before this operation weighed 
7 grammes ; and those which we extracted amounted to 26 grammes. The 
result of the operation was most fortunate : on the twentieth day the patient 
was completely cured, and was able to visit me at Avignon. 

This result must be allowed to be infinitely preferable to that which must 
have been produced by lithotrity. This proceeding would have required, per- 
haps, fifteen or twenty sittings, each nearly as painful as lithotomy, and have 
exposed the patient to the risk of fatal cystitis. 

We now come to a case in which lithotrity was impossible, and lithotomy 
was the only resource. 

Case 12. Mademoiselle M. M., aged 30 years, of Malaucene (Vaucluse), had, 
a month previously, introduced a pen-case into the urethra, which escaped, and 
fell into the bladder. She came to me, and, with much hesitation, confessed 
what she had done. I detected the presence of the foreign body by means of 
a catheter, and endeavoured, but in vain, to extract it with Heurteloup's litho- 
trite. It was easily seized ; but, on attempting to extract it, resistance was 
encountered, and the patient was put to great pain. It was evident that the 
foreign body lay transversely, and that it was probably impossible to make it 
change its direction. We proposed lithotomy, which was immediately accepted. 
On the 19th June, 1847, having perfectly etherized the patient, I operated with 
a lithotome, making the incision directly upwards. I introduced the index 
finger of my left hand, and discovered that the body was actually placed trans- 
versely : I caused it to assume a longitudinal direction, and introduced a pair 
of polypus forceps along the finger, by the aid of which I extracted the sub- 
stance without difficulty. It was almost entirely covered with an incrustation 
of phosphate of lime ; there was a depression at the point where it had been 
seized by the lithotrite: it was 8 centimetres in length, and weighed 3 

The rapid success of this operation could not have been surpassed. Eight 
days after the operation, the patient was able to return home perfectly cured. 

It is somewhat remarkable that, a few days after, I read in the Bulletin de 
VAcademie (15 July, 1847), an account of a perfectly similar case to that which 
I have just related, occurring in a male. As in my patient, lithotrity was im- 
practicable, and lithotomy was followed by cure. 

Lithotrity. Case 13. M. P., of Avignon, aged 68 years, had long suffered 
from calculus ; but he would not consent to lithotomy. The pain, however, 
becoming more severe, the general health being impaired, and the urine de- 
positing a glairy fetid matter, he was compelled to decide on an operation, and 
chose lithotrity. On the 25th January, 1832, after having previously calmed 
the patient with baths and refreshing drinks, we proceeded to the operation, 
using M. Civiale's instruments, which were then generally employed. Although 
I had several times performed lithotrity on the dead body, and had demon- 
strated it to the pupils at the hospital, this was the first occasion of my ope- 
rating on the living subject. 

The instruments were introduced easily enough ; but there was difficulty in 
seizing the stone, from its large size, and from the contracted state and excess- 
ive sensibility of the bladder. At last, however, the stone was seized, and 
perforated in several points, by slightly relaxing the hold and rotating it. This 
sitting lasted eight minutes. A pretty large quantity of detritus was passed 
on the same day ; on the next, the patient felt tolerably well ; but, two days 

1849.] Surgery. 235 

after, there was tenderness and tension in the hypogastrium, with difficult pas- 
sage of urine. This was ascertained, by means of a sound, not to arise from 
the retention of a fragment of the calculus in the urethra. A large number of 
leeches were applied ; and baths, lavements, with calmative draughts and ap- 
plications, were prescribed ; but nothing could arrest the progress of the in- 
flammation of the bladder. The patient went on getting worse, and died on 
the 26th February, a month after the operation. Although the cystitis only 
appeared on the third day, and death did not take place for a month, we think 
that no one can doubt that the lithotrity was the cause of death. At the 
autopsy, we found the calculus broken into numerous fragments. It weighed 
altogether 52 grammes, and the nucleus bore the mark of the perforator. The 
mucous membrane of the bladder was red, softened, and covered with a layer 
of purulent mucus, having the appearance of a false membrane. The perito- 
neum presented some red points of inflammation. The abdomen was dis- 
tended with gas ; this had distressed the patient during the whole course of his 

Case 14. M. R,., of Orange (Yaucluse), had lithotrity performed by M. A. 
Jourkoski, on the 3d of October, 1841. I was not present at the operation, but 
only know that percussion instruments were used, and that there is no reason 
to doubt that it was performed skilfully. On the 5th of October, two days after 
the operation, I was called to the patient, who was in a state of ardent fever, 
with burning skin, tension, and pain in the abdomen, and difficulty in micturi- 
tion. By aid of the catheter, I recognized the presence of a calculus, and drew 
off a large quantity of urine. The patient felt great pain in the bladder, and 
earnestly requested me to relieve him by an operation. I confined my treat- 
ment, however, t» calmatives and antiphlogistics, but without any hope of a 
favourable result. In this I was not mistaken, for the patient died on the fol- 
lowing day. An autopsy was not made. In this case, death was so evidently 
and rapidly the result of a single sitting of lithotrity, that we do not think 
that the most ardent admirers of this operation can mistake it. We will now 
relate some successful cases. 

Case 15. E. B., aged 16, of Tarascon (Bouches-du-PJione), had been suffering 
for about a year, and was supposed to have a calculus. He came to Avignon 
to consult me ; I recognized the presence of a small stone, and proposed litho- 
trity, to which he consented. On the 5th of March, 1832, we operated with 
Civiale's instrument. The instrument was easily introduced, and the calculus 
was readily seized and broken up, being small and friable. The patient expe- 
rienced severe pain during the search for the calculus, but afterwards did not 
complain. A pretty large quantity of detritus was passed in the warm-bath, 
and a larger quantity during the night ; some of the fragments were rather 
large, and gave some pain. The whole of the detritus weighed 3 grammes. 
The next morning, the patient had no pain, and, though we sounded him on 
several occasions, we could discover nothing in the bladder. He was evidently 
perfectly cured. If lithotrity were always attended with such results, it would 
be one of the most splendid operations. 

Case 16. M. J. A., aged 82, of Avignon, presents us with an interesting case. 
He was a timid man, who had suffered for a number of years, but had never 
been able to determine to be operated on, not even to be sounded. At last he 
consented ; and I recognized the presence of several apparently hard and re- 
sistant calculi, which gave a very distinct sound on being struck. Lithotrity 
seemed the only practicable operation ; it was accordingly performed for the 
first time on the 25th of February, 1833, with M. Heurteloup's instruments. 
The canal was very large ; the instrument was easily introduced, and I soon 
seized a largo calculus, about the size of an egg, which offered some resistance 
to the action of the lithotrite, but which I succeeded in breaking down. The 
patient groaned a good deal, but did not seem to suffer much ; he appeared to 
have more fear than pain. He immediately voided a considerable quantity of 
detritis. Four days after, the operation was repeated with the same results, 
and we were obliged to have recourse to it fourteen times. He was under treat- 
ment up to the end of October ; and there were several circumstances which 
gave me anxiety. On several occasions, the operation was followed by an attack 

236 Progress of the Medical Sciences. [July 

of violent fever ; and the patient each time became more impatient of the ope- 
ration, and appeared to suffer more. At last I had the happiness of telling 
him that I could find nothing in his bladder. The disappearance of pain con- 
firmed my diagnosis ; and, in spite of his advanced age, M. J. A. was restored 
to health. 

It cannot be denied that, in spite of the pain and of the difficulties attend- 
ing the operation, the success was due to lithotrity. The detritus, as far as 
they could be collected, weighed 20 grammes ; but it is probable that the 
patient lost a considerable quantity. 

Case 17. M. B., aged 22, of Bollenes (Vaucluse), had suffered for several 
years from a single and rather small calculus ; his general health was good. 
On the 9th of May, 1840, we performed lithotrity with M. Heurteloup's instru- 
ment, and repeated the operation thrice subsequently. The patient returned 
home, perfectly cured, on the 9th of June. The detritus of the calculus 
weighed 6 grammes. 

Case 18. M. A. A., aged 22, of Cebagola (Corsica), presents us with an 
analogous case. First sitting, 21st of March, 1842. Calculus of moderate size, 
but hard ; operation performed with percussion instruments ; cured on the 19th 
of April, after five sittings. We collected 15 grammes of detritus. 

Case 19. M. P. R., aged 17, of Avignon, was as fortunate as the two preceding 
patients. On the 15th February, 1843, we operated for the first time ; but the 
narrowness of the canal caused considerable resistance and pain. The calculus 
was small and friable ; in fact, the smallest I ever met with. The collected 
fragments weighed 10 grammes. The operation was repeated four times, at 
intervals of a few days ; on each occasion, fever supervened. The patient was 
cured in the space of a month. 

Case 20. M. M., aged 25, of Borey (Haute-Saone), had suffered several years 
from stone. He told me that M. Petrequin had discovered the existence of 
one, at Lyons ; but he had not been able to determine to submit to an opera- 
tion. Having, however, seen a patient, at Avignon, on whom I had operated, 
he requested me to perform lithotrity. To this I consented, and, on the 14th 
January, 1844, operated for the first time. The stone was large: the graduated 
scale on the instrument indicated 35 millimetres ; it was easily broken down, 
but offered some resistance, which increased towards the centre. The patient 
experienced some pain, from the retention of one of the fragments in his 
urethra, and I was obliged to remove it with a three-branched forceps. The 
operation was repeated six days after, and, in all, nine times. The patient 
was under treatment during two months, and was found to be cured on the 11th 
March. The calculus weighed 30 grammes ; it was formed of two layers; the 
external, soft, friable, consisting of phosphate of lime ; the internal, hard, 
brittle, composed of uric acid. 

Remarks. When we take into consideration the duration of the treatment, 
the number of sittings which were necessary, the necessity of using Hunter's 
forceps to search for fragments — we may ask, whether lithotrity possesses any 
marked advantages over lithotomy. It will be seen that, out of sixty patients 
operated on by my father, there were only five deaths, or one in twelve. I have 
arrived at exactly the same result : of nine patients on whom lithotomy was 
primarily performed, one died ; and of three, in whom lithotomy was preceded 
by attempts at lithotrity, none died ; which gives one death in twelve cases of 

In lithotrity, I have been less fortunate ; for, in eight operations, seven by 
myself, and one by another operator, two patients died. This gives a proportion 
of one in four. I have three times found lithotrity useless, or attended with 
such inconvenience that I was obliged to have recourse to lithotomy. I know 
that it will be said that I do not praise lithotrity because I do not know how 
to perform it. This reproach, however, has been addressed to my illustrious 
masters, MM. Roux and Velpeau. 

My father had five relapses among fifty-six cases ; and in the case of M. 
Baldy, of Nimes, I found a calculus in the tissue of the perineum. In seventy- 
two operations, then, there were six cases of relapse. I would desire much to 
know whether, in an equal number of cases of lithotrity, there would not be 
a greater proportion of relapses. — London Journal of Medicine, March, 1850. 

1850.] Ophthalmology. 237 


47. Malignant Tumour in the Orbit successfully extirpated. — Thomas Paget, 
Esq., of Leicester, relates in the Provincial Medical and Surgical Journal 
(March, 1850), the following case: — 

"George Lee, aged 19, was admitted into the Leicester Infirmary with his 
left eye protruding from its normal situation at least three inches. It is worthy 
of note that, though the optic nerve was stretched to this length between the 
foramen and the globe, vision was not destroyed. He could see with either eye 
singly. There was, at times, much pain deep in the orbit and on that side of 
the forehead. This mischief was effected by a tumour, which filled and pro- 
jected beyond the orbit, thrusting the eye before it. It was of a lobulated form, 
and showed in parts a livid tinge. He came with a full determination to have 
it removed, if possible. 

"I find the entry made on his admission runs: — 'Hydatid, encephaloid, or 
botryoidal tumour, arising within the orbit ;' and on consultation, as the 
nature of the case could not be more definitely settled, it was decided not to 
refuse an operation, but to dissuade the patient from it. With this view I kept 
him in the house more than a month, trying my best from time to time to ward 
off the responsibility of surgical interference ; I had, however, promised him to 
remove it, if he wished, and he was firm in insisting upon my promise. I 
never saw more firmness of purpose. 

''The orbit was emptied by excision. All present concurred in the malignant 
nature of the tumour, which now forms a fine specimen in our museum (bottle 
47). It is now five years since the operation, and I have seen him recently 
.(January 24th), entirely free from all appearance of disease, and anxiously 
inquiring about a glass eye, for which the palpebrge are, by freedom, power of 
motion, and natural look, well adapted. This disease had been in progress ten 

48. Melanosis of the Eye. — John Windsor, Esq., Surgeon of the Manchester 
Eye Infirmary, records [Provincial Medical and Surgical Journal, May 1, 1850) 
the two following cases of this disease : — 

Case 1. Ann Drinkwater, residing at 15 Howe Street, Portland Square, be- 
came an out-patient of the Manchester Eye Hospital, August 1st, 1847. Her 
age is 43. The catamenia still appear, although irregularly and rather too fre- 
quently, but sparingly ; her pulse 96 ; tongue clean, and the papillae all over it 
much developed ; bowels costive ; appetite indifferent ; she sleeps in general 
but badly. The left eye is occupied by a dark, red-looking fungus, the size of 
a very large apple; the surface of it is tolerably moist and smooth ; almost the 
superior half is covered by the palpebra, which exhibits a dusky colour, and 
there are some tortuous prominent veins upon it. The tumour extends over 
the inferior palpebra (which, like the upper, is projected forward by it), and 
extended downwards so as to cover nearly the left upper half of the face. The 
sub-maxillary or other glands do not appear enlarged. She has a good deal of 
pain of the head on the affected side and round the tumour ; she can lie easily 
only on the affected side ; otherwise she feels the weight of the tumour un- 
pleasant. The vision of the left eye was lost about three years since ; she was 
suffering at that time a good deal of pain in the part, but nothing particular in 
the appearance was noticed until about three months since, when the eye began 
to project from the orbit, and soon became nearly as large as it is now. She 
can ascribe np cause for the complaint, except it might be child-bearing and 
exposure to cold. She has used no particular remedies, except lately some 
homoeopathic ones. She was prescribed some aperient pills and anodyne pow- 
ders to be taken occasionally, a saturnine lotion and zinc ointment as applica- 
tions to the part. 

19th. There is a gradual enlargement of the tumour of the orbit, and a num* 
ber of small swellings — altogether seventeen — scattered over the surface of the 
body. They feel somewhat like enlarged glands, but present a discoloured 
rather dark bluish hue. 

No. XXXIX.— July, 1850. 16 

238 Progress of the Medical Sciences, [July 

October 6th. Since last report, the orbital tumour has become still more 
enlarged, and has bled a little occasionally. She keeps it covered with linen 
cloths wetted in the lotion. She looks pale and emaciated ; pulse 76 ; tongue 
clean ; bowels regular at present ; is attacked occasionally with sickness and 
vomiting ; sleeps indifferently. She takes occasionally a saline (neutral) mix- 
ture, with a little tincture of opium. Besides the large tumour of the orbit, 
there are now two small ones about the size of a hazelnut, one on each side of 
the upper part of the head. The left mamma is pretty entirely occupied by 
two tumours — one on each side of the nipple ; there is a rather large one oc- 
cupying all that part of the right mamma, situated on the outer side of the 
nipple ; and there are two more on the right side not far from the mamma, one 
loose, just under the integuments, and the other apparently fixed to the rib. 
There are two on the outer side of the right upper arm, and one on the outer 
middle part of the right forearm. There is one on the left side between the 
last rib and the os ilii, and a small one on the abdomen, a little above the um- 
bilicus. In the right groin there are three or four small ones. Above the right 
ilium there are two, and one just behind the base of the scapula. In the lower 
part of the neck there are two, making in all twenty superficial tumours. The 
abdomen is generally tumid, hard, and tender when pressed, apparently from 
the pressure of several large tumours situated more internally than the above- 
mentioned ones. 

Over the superficial swellings the integuments are, in some parts, little 
changed, but in most they present a bluish colour; when pressed these tumours 
feel hard, and she then generally complains of pain. 

November 1st. There is little alteration since last report, except that she 
seems becoming gradually weaker. The tumours of the abdomen are numerous, 
large, and sore when touched, and, though not individually projecting, the ab- 
domen seems generally prominent from them. The pulse is of moderate fre- 
quency and strength ; tongue pretty clean ; bowels irregular, being sometimes 
confined and sometimes relaxed ; stomach occasionally disturbed with sickness 
and vomiting, at other times she has a tolerable appetite. She still uses the 
same means internally and externally. 

January 15th, 1848. No great change since last report ; the tumour of the 
eye is still larger, reaching now to near the angle of the mouth; it sometimes 
bleeds a little. 

February 21st. For the last few days she has felt lower, with a good deal of 
nausea and occasional vomiting ; her bowels have been rather relaxed ; the 
fungoid tumour of the eye has bled rather more of late ; she has occasional 
shooting pains through it, as well as through the other tumours, of which she 
reckons now sixty-one, without including a few upon her head ; many of them, 
especially those situated quite superficially, and which are slightly prominent, 
present a bluish venous-like appearance, but over a great number of them the 
integuments are not discoloured or elevated ; the abdomen is now almost every- 
where studded with them. Continue saline mixture, opiates, saturnine lotion, 
and zinc ointment. 

April 11th. She died this day. Since the last report the complaint had been 
gradually developing itself more and more in the number and increasing size 
of the melanotic tumours, and also in the wearing down of the constitution, 
although she appeared to bear her very suffering state with much fortitude ; 
she became more and more emaciated in her limbs, whilst the bulk of the ab- 
domen gradually increased ; her pulse was nearly natural in frequency ; her 
tongue generally clean ; her appetite mostly indifferent, and the little food 
taken often partially or entirely rejected; her bowels irregular, being some- 
times rather confined, but more frequently passing small and rather frequent 
dejections ; she complained of a good deal of pain of the abdomen at times, 
and also of the head and eye, the last bleeding a little occasionally. About a 
month before her death a little oedema of the legs appeared, and distinct fluc- 
tuation of fluid in the abdomen was detected, which gradually increased ; I 
therefore passed a trocar on the 4th of April, and drew off ten pints of a yel- 
lowish serum. A good deal of fluid continued to issue through the puncture 
for the two following days. 

1850.] Ophthalmology. 239 

On examining the abdomen after the tapping, it felt as if filled with a great 
number of large round balls. She was not, however, materially relieved by 
the operation ; the pulse became very small and feeble, beating about 9G in the 
minute ; there was some vomiting at times, and a discharge of small, scanty, 
dark-coloured evacuations occasionally from the bowels ; urine of a darkish 
yellow colour, and very turbid ; the extremities gradually became colder, with 
failure of the pulse and facies Hippocratica. She died at 10 A. M., an hour 
afterwards, being sensible to near the last. 

A post-mortem examination was made about thirty hours after death. The 
external appearances of the surface of the body were much the same as during 
life. Upon raising the sternum there appeared, partly adhering to it, and 
partly to the division of the pleura or anterior mediastinum, a melanotic tumour, 
about the size of a walnut ; the left mamma consisted apparently of several 
melanotic tumours, viz., of two large ones, each about the bulk of a pullet's egg, 
and of two smaller ones, each about the size of a filbert ; the right mamma 
presented nearly the same appearance, only consisting chiefly of two melanotic 
tubercles, one about the size of a pullet's egg, and the other that of a nutmeg. 
In the integuments a little below the right mamma there was a similar tumour, 
about the bulk of a hazelnut ; nearly in the same situation, between the in- 
teguments and ribs, another appeared, adherent to the intercostal muscles, and, 
like most of the others, apparently contained in a thin envelop or cyst of cel- 
lular substance ; in the right lateral portion of the thoracic and abdominal 
parietes appeared about a dozen melanotic tubercles, adherent to the integu- 
ments, and varying in size from that of a large filbert to a pin's head ; about a 
similar number, but generally of a smaller size, appeared partly on the surface, 
and partly in the substance of the right lung ; two or three, rather firmly ad- 
herent, were found close to the spinal column, just under the pleura ; and on 
the left side similarly situated were two more, each about the size of a walnut. 
Both lungs were considerably adherent to the parietes; about half a dozen 
melanotic tubercles appeared on or near the surface of the left lung. In the 
substance of the heart there were several nearly similar tubercles. The liver 
was extraordinarily enlarged, occupying a great portion of the abdominal 
cavity, below extending to the ilium, and even to the pubes, also pushing up 
the diaphragm as high as the fourth rib ; its natural structure was completely 
masked in an immense number of tubercles; on the outside of the left lobe, 
immediately under the peritoneal covering, there were about twenty, from the 
bulk of a hazelnut to that of a pullet's egg, or even larger ; on the right lobe 
an innumerable crop of tubercles appeared; indeed the texture of the liver, large 
as the organ had become, seemed almost completely made up of the melano- 
tic tumours. On the omentum there were also many, varying in bulk from that 
of a large pea to that of a large pullet's egg. On the surface of the right kid- 
ney there were four large ones, and in the substance of this organ, between the 
surface and tubular portion, about half a dozen appeared, nearly the size of a 
large pea; on the surface of the left kidney there were five or six, from the size 
of a pea to that of a nutmeg, and one of about the same bulk as the last was 
situated somewhat more internally ; on the right side, between the right kidney 
and the os ilii, there was a very large melanotic tumour, equalling the bulk of 
a pretty large turnip ; it was, like the others, filled with a black, grumous, ap- 
parently unorganized substance, but softer, looking somewhat like thick black 
paint. The spleen appeared pretty natural, except on its superior part, where, 
quite superficially, a few minute tubercles appeared. The uterine surface pre- 
sented a large number of minute tumours. The right ovarium seemed to be 
chiefly composed of a melanotic tumour, the size of a filbert ; the left ovarium 
seemed totally composed of one, as large as a moderate sized apple. There 
were a few about the intestines. On the head, between the scalp and cranium, 
there were six tumours, of various sizes. Neither the brain nor the interior of 
the blood-vessels were examined. 

Case 2. The next case of melanosis of the eye which I purpose describing, 
occurred in the person of John Bramwell, aged 58, from Derby, who applied 
to me 10th of September, 1848. The appearance of the eye as to colour and 
projection, with the consequent tension of the palpebrae, was very similar to what 

240 Progress of the Medical Sciences. [July 

occurred in Mrs. Jackson, and like her, when she first applied, he appeared to 
be in other respects healthy, and of a fresh ruddy complexion. The right eye 
projects considerably from the orbit. The natural appearance of the organ is 
lost, there being no sclerotic, cornea, iris, or pupil distinctly visible. The front 
of the eye presents an irregular surface from the palpebrae being strongly 
pressed forwards by three or four tubercular prominences situated behind them. 

He lost the sight of the eye gradually about nine years since without the 
occurrence of any particular redness or inflammation; but for some time pre- 
viously he had been troubled with frontal and temporal pain, or what he calls 
tic douloureux, and he knows of no other cause for the complaint. The eye has 
gradually enlarged for the last two or three years, and especially during the 

October 1st. — Since he called upon me before, the eye has still further en- 
larged ; the palpebrae are much distended by it, and the projections appear still 
more prominent ; he has at times a good deal of shooting pain through the 
part. The adjoining parts and neighbouring glands seem to be unaffected, and 
his general health being apparently good, it was determined to have the dis- 
eased eye excised, which was done in the usual way, in the presence of my 
colleagues at the Eye Hospital. At his own request chloroform vapour was 
previously inhaled ; by it the pulse was first excited, and rose to about 120 in 
the minute, with flushed face, and much congestion of the frontal veins, fol- 
lowed by a rather contrary state, the pulse sinking to 72, and the countenance 
becoming pale. In this latter state, the operation was performed. His feelings 
were benumbed, but he was not entirely unconscious of pain. 

The eye being removed, the orbit was cleared of a good deal of remaining 
blackish substance, and care was taken to remove as much as possible the 
thickened vasculo-nervous matter at the very base of the orbit, from which 
there was a rather considerable flow of blood. Some lint was applied, and 
supported by a light bandage. An opiate was given to him, containing four 
drops of laudanum. A good deal of sanguineous oozing continued through the 
day. He went on afterwards pretty well. 

The dressings were not removed till the fourth day ; then he was dressed 
every other day for two or three times ; afterwards daily. 

The discharge was at first offensive, chiefly from the decomposing blood in 
the orbit, but in about a week the cavity looked clear, and filling up with florid 
granulations, being well washed out with a syringe at each dressing, and the 
palpebraB then simply covered with a little lint and adhesive plaster. 

For the first few days after the operation, he took some antimonial saline 
mixture, and an aperient occasionally ; but his pulse and general health were 
scarcely disturbed. On dividing the tumour immediately after the operation it 
presented throughout the character of melanosis. He was soon well enough 
to leave Manchester. 

November 4th. — He came over again to-day for examination. He has no 
pain, but a feeling of some numbness on the right side of his face. The orbit 
is nearly filled up with granulations, and the lids are gently inclined towards 
it. His general health is good, he still washes the part once a day with a 
syringe and water, and applies a little lint and adhesive plaster. 

December 26th. — He came over again to-day; he looks well and complains of 
nothing; has no pain of the orbit, which seems healed, and the palpebrae are 
somewhat inverted towards it. 

He promised to return or inform me if anything particular occurred, but I have 
not heard of him since, and therefore hope that he continues quite well. 

49. Coincidence of Albuminuria and Amaurosis. — Dr. Landouzy, in a paper 
in the Gazette MMicale de Paris (Oct. 20th, 1850), maintains that impaired 
vision is an almost constant symptom of that form of renal toxaemia, which is 
indicated by an albuminous condition of the urine. We have lately seen an 
interesting case of this coincidence. The following are Dr. Landouzy's con- 
clusions : — 

1. Enfeebled vision is a symptom almost constantly present in albuminous 

1850.] Midwifery. 241 

2. It is the earliest symptom of albuminous nephritis. 

3. It disappears and returns simultaneously with the albuminous condition 
of the urine. 

4. Albuminous nephritis ought to be considered as dependent upon an altera- 
tion in the ganglionic system of nerves. — Loncl. Journ. Med., Feb., 1850. 


50. New form of Obstruction in Head Presentations, from Posterior Displace- 
ment of the Arm. — Professor Simpson stated to the Edinburgh Obstetrical 
Society (Feb. 13), that he considered the case to which he wished to direct the 
attention of the society an important one, because the peculiar obstruction in 
head presentations, which it illustrated, was, so far as he knew, hitherto un- 
described. The form of obstruction consisted in one of the arms of the infant 
being displaced backwards across the neck or occipital region ; or more properly 
speaking, it was the forearm that was thus thrown across the back of the head 
and neck, the arm being thrown upwards in a line with the body, in order to 
admit of this malposition of the forearm. In this abnormal position the dis- 
placed elbow and forearm of the child, first increased greatly the dimensions of 
the basis of the head ; and secondly, these same parts formed a kind of pro- 
jecting obstruction, which readily hitched and caught upon the brim of the 
pelvis, thus preventing the descent of the head. But the effects might be 
better judged of by detailing the case itself. 

The patient had previously borne nine children. All the labours had been 
easy, and she had frequently been delivered so speedily, that the labour was 
over before the medical attendant could reach the house. In her last and 
tenth labour, pains came on about four in the afternoon, and the os uteri 
was not completely opened up till about ten o' clock. About an hour before, 
the membranes ruptured. At six next morning, Dr. S. received a note 
from her medical attendant, Mr. Charmichael, asking him to see her, as the 
head had remained in the same position at the brim for several hours, the 
uterine contractions were becoming weak, and the woman herself exhausted. 
On placing the patient deeply under the influence of chloroform, in order to 
make a complete examination, Dr. S. found the maternal passages perfectly re- 
laxed and open, and the head of the child to be by no means large, and not 
even entirely filling up the brim. The vertex presented, and the face was 
directed towards the left sacro-iliac synchondrosis — a rare enough position, but 
one not in any degree calculated to account for the delay. On passing the ex- 
amining fingers farther upwards in order to trace any possible obstruction, Dr. 
S. touched a projecting body (the elbow) beyond the left ear of the child; and 
on now making the examination more carefully, he traced this body backwards 
across the neck of the infant and found it to consist of the left forearm of the 
child thrown back posteriorly behind the head. Dr. S. then brought the hand 
downwards and forwards, believing that if it were converted into a head and 
arm presentation, the case might terminate without further interference. 
During the next half hour, however, the pains, which had for some time been 
weak, had little effect in forwarding the presenting parts, and as the child's 
heart had now sunk as low as 78 beats in the minute, Dr. S., in order to preserve 
the child, again chloroformed the patient deeply, and delivered the child by 
pedalic turning. The mother made a speedy recovery. The child soon cried 
strongly, and goes on quite well. Its left arm was for a day or two after 
delivery easily thrown into the position described. The occipito-frontal cir- 
cumference of the head was afterwards measured by Mr. Carmichael, and 
found to be 14£ inches; when the arm was placed in its anomalous position, 
the same circumference measured 15 £ inches. The circumference of the 
shoulders was 13^ inches. The child was of about the usual size, and weighed 
U lbs. 

The treatment of such a cause of obstruction, when it was once recognized, 
should probably consist of bringing the hand downward and forward over the 

242 Bibliographical Notices. [July- 

side of the head, so as to convert the case into one of simple presentation of the 
head and arm. Perhaps it might occasionally be possible to push the elbow 
forwards in the direction of the lower end of the sternum, and thus draw back 
the displaced arm into its normal position in front of the chest. If either of 
these measures proved impossible, or failed, then the pedalic version would be 

The diagnosis of the case was the most difficult point in its management. 
And in this, as in other complications — as detention from intra-uterine hydro- 
cephalus, &c. — the assistance of anaesthetics in midwifery was invaluable as a 
means of enabling the accoucheur to make a far more effective, and searching, 
and successful manual examination and diagnosis, in cases of obstructed 
labours, than it was possible to do when the patient was awake and incapable 
of bearing with steadiness, and without unnecessary suffering, the introduction 
of the hand for the purpose. 

When a labour, as in the preceding case, notwithstanding steady and con- 
tinued uterine contractions, becomes morbidly prolonged in a mother who had 
previously borne easily a large family, there was every probability of obstruc- 
tion of some kind on the part of the infant. Dr. S. had seen two such cases, 
where the detention was the result of intra-uterine hydrocephalus. In the 
present instance, it was the result of the malposition of the hand. Some time 
since he had mentioned to the society two cases of tedious labour, which, 
several years ago, he had seen with Dr. Ziegler: in both, the head, despite of 
strong pains, remained in the pelvic brim without descending ; in both the head 
was evidently not disproportionately large to the maternal passages ; in both 
some point of the shoulder or arm could be touched by the finger on examina- 
tion ; and, perhaps, if the examination could have been made more complete 
by the use of ether or chloroform, which were then unknown, a malposition of 
the arm, similar to the one above described, might have been detected. Various 
cases are recorded of obstructed labours, with the head, as usual, presenting, in 
mothers who had previously had natural deliveries, and where the forceps 
failed to extract the child, and where even extraction after craniotomy was 
difficult. Some of these cases were in all probability instances of obstruction 
from dorsal malposition of the arm, or rather of the forearm. The late Dr. 
Campbell, shortly before his death, told Dr. S. of a case where there was no 
pelvic or other deformity on the part of the mother, no want of uterine con- 
traction, and no disproportionate size of the head of the child, and yet he and 
others had entirely failed in extracting the detained infant by the forceps, and 
at last were obliged to open its head. 

When looked for, Dr. S. believed, therefore, that the dorsal malposition of the 
forearm would be found a more frequent cause of obstructed labour than the 
total silence of obstetric authors on the subject might, a priori, lead us to sup- 
pose. Further, he considered the present case as interesting, not only as an 
instance of an undescribed species of malposition and obstruction, but probably 
as one of a new class of malpositions as yet unrecognized in any of our accounts 
of the mechanism of labour, and the malpositions of the child. It would pro- 
bably be found that other degrees and forms of malposition of the arm might 
occasionally lead to the same result. 

Dr. Gumming said that he had a distinct recollection of the case mentioned 
to Dr. Simpson by Dr. Campbell. The late Mr. John Kennedy had been in at- 
tendance on the patient during the greater part of the night. The labour had 
advanced regularly and naturally till the os uteri was of a tolerable width, and 
the vertex had descended some way into the pelvis, then, though the pains 
continued sufficiently powerful, though the head of the child was quite mov- 
able, and the soft parts of the woman were perfectly relaxed, no further ad- 
vance was made. About mid-day Mr. K. sent for Dr. Cumming, expressing 
himself unable to account for the arrest of the labour. On examination, Dr. C. 
found matters exactly as they had been described, and was at first disposed to 
account for the retardation by the hand being tilted up under the chin ; but on 
further consideration abandoned this idea, as in all the cases he had seen of delay 
from this cause, the head had descended deeper into the pelvis than in this case. 
Mr. K. and Dr. C. waited on for several hours, during which various efforts were 

1850.] Midwifery. 243 

made to ascertain the cause of arrest ; but as these were unavailing, as the 
pains were becoming more inefficient, and tenderness of the abdomen was 
threatening, they resolved to apply the forceps. The instruments were accord- 
ingly applied without difficulty, and Mr. K. used all the exertion he thought 
justifiable, but without the slightest effect. Dr. C. then made similar exertions 
equally fruitless. After a time Mr. K. resumed, and Dr. C. again followed 
him, but with the same result. At this stage they deliberated as to their next 
course of procedure. The head had not advanced in the slightest degree in spite 
of all their traction ; it was still quite unimpacted and movable. There was 
no discoverable contraction of any of the dimensions of the pelvis. It was the 
third or fourth pregnancy, and in her previous labours the patient had had no- 
thing uncommon, certainly nothing instrumental. What could be the cause of 
arrest? They confessed themselves fairly baffled, and sent for Dr. Campbell, 
who lived in the neighbourhood, and who, with his usual kindness and prompt- 
itude, was soon at the bed-side. On his first examination, he was inclined to 
think that his less experienced friends had been premature in their resort to 
the instruments, and hinted disapprobation. Operations were therefore sus- 
pended till he should see the effect of the pains. He was soon satisfied that, 
for the woman's sake, if not for the child's, the use of the forceps was advisable. 
They were applied, and he pulled at first with great caution and forbearance, but 
with the same result as his friends. To shorten the details, the three doctors 
pulled in succession with all the force they thought justifiable, but without 
effecting the slightest advance. The state of the woman now indicated that no 
further delay should take place. Dr. Campbell accordingly used the crotchet, and 
the delivery was soon accomplished. Dr. Cumming has no distinct remembrance 
of what occurred after the extraction of the head, nor is he aware that there was 
any mark about any portion of the child to indicate the cause of detention. In 
subsequent conversation, it was confessed that to all the three doctors it was a 
mystery ; but Dr. Cumming said that he could well believe it to have been such a 
case as that so distinctly and satisfactorily made out by Dr. Simpson. Had the 
chloroform then been in use, the examination might, and probably would, have 
beon made with more boldness, freedom, and success. 

Dr. Simpson observed, that sometimes, in women who had previously borne 
a large family, a cause of obstruction might exist in a late labour, not on the 
part of the child, as was generally the fact, but on the part of the uterus. 
Last summer he saw, with Dr. Skae, a case of this kind, where the source of 
detention was a firm and contracted circular band of the uterus around the 
site of the neck of the child. — Monthly Journal, April, 1850. 

51. Case of Spontaneous Expulsion of tlie Cliild. — The following case, of what 
was termed by Denman " spontaneous evolution," read before the Medico-Chi- 
rurgical Society of Aberdeen, by Dr. Robert Dyce, and published in the Monthly 
Journal of Medical Science, May, 1850, is interesting, not only for its extreme 
rarity, but also for the many untoward circumstances which accompanied it : — 

"I was called about midnight on Saturday, 30th December, 1848, by a mid- 
wife, to visit Mrs. C , the wife of a tradesman, living in Castle street. I 

was informed that labour had commenced in the evening about six hours before 
— that the presentation remained long high — that the membranes ruptured 
naturally — that the waters were in great quantity — and that several strong 
pains had followed after the discharge of the waters, before any part of the 
child could be felt — a limb was at length reached, which was made out by her 
to be an arm. When I first saw the patient she had very strong forcing pains; 
the arm was at the top of the vagina, doubled up so as to present the elbow. 
A part of the child, nearly equal in bulk, was felt on either side of the pre- 
senting limb, viz : one part near the pubes, and the other near the sacrum, but 
so high that, unless I had passed my whole hand into the vagina, which I did 
not at the time deem essential, the individual parts could not be made out. It 
was sufficient for my purpose that the arm presented, and that delivery could 
not be accomplished without turning the child. In order, therefore, to render 
the operation easier, by quieting the uterine action, which was very powerful, 
I gave her, as soon as it could be procured, a teaspoonful of laudanum, deter- 

244 Bibliographical Notices. [July 

mining to operate the moment a lull took place. This, however, never hap- 
pened, for presently the pains forced the elbow lower, the hand came down into 
the vagina with hardly any assistance, and was ascertained now to be the right 
one. At this time the proportionate size or bulk of the two parts of the child 
became remarkably altered. The arm, shoulder and neck, which formed one 
part, pressed towards the pubes, and appeared smaller ; while the other end of 
the tumour, which was now distinctly made out to be the back of the child, 
along with the ribs and spine, which was twisted and bent, now came com- 
pletely to occupy the hollow of the sacrum. It now became very apparent that 
nature was to complete the delivery herself, by expelling the child double, or 
by what is called spontaneous expulsion. At length, after two or three power- 
ful pains, the shoulder was very closely pressed, or jammed rather, against the 
arch of the pubes, and at length external to the vulva, while the breech pressed 
out the perineum, and was expelled by a very long and powerfully continued 
pain, the feet following quickly in its wake, the arm never moving from its po- 
sition under the pubes. The head soon followed, and the delivery was speedily 
completed. The child (a girl) gasped once or twice, but could not be re- 

The size of the abdomen indicated the presence of another child, which, on 
examination per vaginam, was confirmed, as the membranes were reached. I 
also discovered in the examination a circumstance by no means desirable, viz. : 
that the integuments of the abdomen, limbs, face, and in short, the whole body, 
were extensively oedematous, for lying, as the patient did, with her back towards 
me, I had no opportunity of discovering this before. 

No pain coming on in half-an-hour, the membranes were ruptured. The 
waters were in very great quantity. An arm again presented, but along with 
the head. It was attempted to keep up the limb, so as to let the head descend 
alone ; but the pains were so violent that both head and arm were forced into 
the pelvis, and expelled together. The breech remained during two or three 
equally severe pains at the birth, owing to the cord, which was very short, 
being twisted round one thigh and leg, by which it was tucked up tight upon 
the infant's abdomen ; its removal immediately caused the expulsion of a se- 
cond girl, alive and strong. In a quarter of an hour pains returned, but no 
part of the placenta could be felt ; and as the uterus felt contracted, small and 
tolerably defined, while no hemorrhage at first ensued, no interference was 
resorted to. Very shortly, however, the pains became very severe, along with 
hemorrhage to some extent, so as to lead me to fear that irregular contraction 
either had taken place or was impending, and that probably one of the pla- 
centae might be separated. The hand was immediately introduced. One 
placenta was found loose in the lower part of the uterus, a portion of the other 
in the contracted part, while by far the largest portion was imprisoned above, 
in the upper chamber of the uterus. The usual methods were carefully tried 
to separate the placenta, viz., by patting it, by grasping it from its edge to its 
centre, while the uterus was steadied by the hand on the abdomen externally ; 
but no impression was made upon it. It was then attempted to remove it bit 
by bit ; but so firmly was it attached, and to so very large a surface, that I for 
a moment hesitated what was best to be done — whether to persevere carefully 
in my present proceeding, or to leave some of the lobules adhering to the 
uterus. Both methods were attended with danger ; but knowing well the great 
risk there is in separating a strongly and morbidly-adherent placenta, from the 
difficulty in distinguishing the soft and loose structure of the Womb from the 
mass of the placenta, I decided on the latter method. I therefore kept my 
fingers close to the placenta and pinched off several of the lobules and left 
them adhering to the uterus. The womb now contracted regularly, and 
expelled my hand and the placenta together. Hemorrhage ceased, and the 
pulse, when I left at two in the morning, was 86. The woman had a most per- 
fect recovery. 

52. Lingering Labour from a Stricture of the Uterine Parietes around the 
Child's Neck. — Dr. Skae stated (Meeting of the Edinburgh Obstetrical Society 
Feb. 13), that accidental stricture of the uterus during labour, and especially 

1850.] Midwifery. 245 

before the separation of the placenta, as a consequence of irregular or spas- 
modic contraction of its walls, was an occurrence by no means unfrequently 
met with ; but the following case of uterine stricture was one of quite a differ- 
ent character. The contraction was of a permanent kind, and probably had 
been developed in the course of utero-gestation, offering an insuperable barrier 
to the progress of labour, so far as the effects of antispasmodic treatment could 
be brought to bear on it. Its relation, indeed, to accidental stricture is so 
similar to that between accidental and unavoidable hemorrhage as to warrant 
its being called unavoidable stricture. The patient in whom it occurred com- 
plained of a feeling of tightness across the lower part of the abdomen during 
the three last months of gestation, and had a strong impression on her mind 
that all was not right with her, for she had on no former occasion experi- 
enced the same feeling, although she had had a large family, and once or twice 
twins. The particulars were as follows : — 

Dr. S. was sent for by Mrs. C. on the morning of Tuesday, the 12th of June 
last, as she thought herself in labour. Examination discovered no indication of 
incipient parturition, and an opiate, followed by castor oil, was prescribed, on 
the supposition that the pains, which were said to have been steady and 
severe for some hours, were of the ordinary character of the spurious pains 
which so frequently precede labour. Notwithstanding repeated opiates, how- 
ever, the pains abated but little during the subsequent forty-eight hours, when 
dilatation of the os uteri began to show itself. During the whole of Thursday 
the 14th, labour progressed favourably, so far as dilatation of the os was con- 
cerned ; but it was only about four or five o'clock that the presentation could 
be distinctly made out, when the head could be found to descend to the brim 
during the pains. The patient continued suffering, apparently from severe 
labour pains, with but little change in the position of the foetal head till past 
midnight. The head descended, during the pains, to the brim of the pelvis, but 
never entered it, although an attempt was repeatedly made to steady it in its 
most favourable position for descent. (Edema of the os uteri now showed itself, 
and the strength of the patient began to flag. Dr. S. therefore made two or three 
attempts to bring her under the influence of chloroform, but unsuccessfully, for 
she resisted with all her strength, being firmly determined not to take it ; and 
his only assistant was an elderly female, who was worse than useless from alarm 
and agitation. By this time he felt satisfied that the obstruction to labour must 
be of some unusual kind, for the pelvis was large and well formed, and the 
size, firmness, and configuration of the child's head opposed the idea of hydro- 
cephalus. He therefore sent for Dr. Simpson, at 2 A.M., and they succeeded in 
speedily putting her under a full dose of chloroform, when the cause of obstruc- 
tion was found to depend on the presence of a rigid stricture, situated in the 
lower third of the uterus, upon which rested the shoulders of the foetus. After 
administering 120 drops of sol. mur. morphia, and keeping her pretty deeply 
under the influence of chloroform for two hours, it was found that no material 
relaxation of the stricture had taken place, to admit of turning without endan- 
gering the integrity of the uterine walls. It was feared that evisceration might 
be ultimately necessary, but employment of the long forceps was resolved upon, 
notwithstanding the unusual difficulty of applying them so high up, as neces- 
sarily to require their being locked within the vagina. Dr. Simpson, however, 
with his accustomed tact and dexterity, succeeded not only in applying them, 
but also in accomplishing delivery in some fifteen or twenty minutes, by drag- 
ing the shoulders of the foetus through the stricture. In this case, both mother 
and child did well, the recovery being unattended by any unfavourable symp- 
toms. — Monthly Journal, April, 1850. 

53. Rare Obstetric Cases. By C. D. Purdon, M. B., of Belfast. — 1. Hydro- 
metra. — A young lady, aged 18, of lymphatic temperament, middle size, chest 
well developed, breasts without any areola, abdomen very large, states that 
about nine months previously the catamenia ceased, after great mental agita- 
tion, and in some weeks she began to have regular attacks of morning sickness, 
and after a short time perceived her abdomen to be enlarged ; from this she 
went on increasing in size regularly until the ninth month, when she appeared 

246 Progress of the Medical Sciences. [July 

in the last stage of utero-gestation. The os uteri was now quite small 
and virgin-like, cervix long and thin, the uterus appearing much depressed ; 
she had slight oedema of the feet. At this time~ she suffered from an attack of 
enteritis, which yielded to the usual remedies ; in some days after, she had a 
slight bloody discharge from the vagina, which soon ceased of its own accord. 
She then had regular paroxysms of apparent labour pains for three consecutive 
nights, being well during the day, when a yellowish coloured serous discharge 
began to issue from the uterus, and continued for four weeks, the abdomen fall- 
ing gradually each day, till at length it attained its usual shape and form. In 
a few weeks she had a regular catamenial discharge. She is now perfectly re- 

2. Vicarious Lochia! Discharge. — Attended Mrs. of her seventh child. 

The labour natural, and everything went on well till the eighth day, when I was 
informed by the nursetender that the lochia had entirely ceased, and that there 
was a reddish-coloured discharge from the rectum. Her pulse at this time was 
only 72, there was no pain on pressure, and she had not the slightest fever. By 
using appropriate means, the lochia, after forty-eight hours, returned to their 
usual channel. 

3. Labour without any Pain in the second Stage. — Mrs. , aged 21, was 

taken ill of her first child, at seven in the morning, and had frequent dilating 
pains for about three hours ; these ceased on the rupture of the membranes, 
and she appeared to be free from all pain, when she suddenly said that there 
was something pressing down, and on going to examine, I found the head press- 
ing on the perineum. The head advanced rapidly with each uterine contrac- 
tion. She lay quite still, with eyes half closed, till the child was expelled, with- 
out any sensation of bearing down, or expressing that she felt any pain. — Dub- 
lin Quarterly Journ., Feb., 1850. 

54. Operation for Calculus Vesica? during Labour. By M. Monod. — A woman, 
aged forty, pregnant for the first time, had been in labour several hours ; the 
membranes were ruptured, the pains frequent, but the labour did not advance, 
by reason of a large tumour on the anterior wall of the vagina. The tumour 
was hard to the touch, and completely filled the entrance to the vagina. From 
its form, position, &c, it was readily recognized as a vesical calculus. A sound, 
passed into the bladder with difficulty, confirmed the diagnosis. 

M. Monod, finding that the operation of lithotrity was inapplicable, at once 
proceeded to remove the stone by an incision into the walls of the tumour. A 
curved bistoury, guided by the forefinger of the left hand, was passed into the 
vagina, and an incision made into the tumour. The stone was removed by the 
finger only; it weighed nearly three ounces ; its surface was irregular, and its 
form that of a shallow bowl. 

The patient had been previously chloroformized, and, as the state of insensi- 
bility continued after the removal of the stone, the forceps were employed to 
complete the delivery. The child breathed, but died in a few seconds, death 
being attributed to the pressure of one blade of the forceps on the umbilical 
cord, which was twisted round the neck. 

The patient recovered with an untoward symptom. The urine passed by the 
urethra on the following day. This M. Monod explained by supposing a swollen 
condition of the edges of the wound produced by the manipulation necessary for 
the removal of so large a calculus through an aperture so small as he had 
made. — Monthly Journal of Med. Science, May, 1850, from L 'Union MCdicale. 

55. Remarkable Case of Retention of Urine after Delivery. — M. Malgaigxe 
was called to a woman on the fourth day after her delivery, in consequence of 
the various attempts at relieving retention of urine by catheterism having failed. 
The abdomen was as much swollen as prior to delivery, and the woman was in 
a state of dreadful suffering. On inquiring, M. Malgaigne learned that both 
she and one of her daughters urinated in a different manner from other females, 
the jet passing upwards' and in front, and he concluded that the urethra mounted 
higher up in front of the pubis than usual, and that this bone had prevented 
the passage of the catheter. By directing the instrument first from above down- 

1850.] Midwifery. 247 

•wards, then turning it, and pushing it upwards and backwards, he easily reached 
the bladder. He was perfectly astonished at the enormous quantity of urine 
that came away, this far exceeding anything he had ever witnessed before. By 
weight it amounted to 3300 grammes, and by measure to three litres, that is be- 
tween eight and nine apothecaries' pounds, or between five and six imperial 
pints. — British and Foreign Medico- Chirurgical Review, April, 1850, from Revue 
Me'dico-Chirurgicale, torn. vi. p. 374. 

56. Cases of Tetanus coming on after Abortion. — Two cases of tetanus coming 
on after abortion, were communicated to the Edinburgh Obstetrical Society, on 
the 13th of February last. The first case, related by Dr. A. Wood, occurred in a 
woman 36 years of age, stout made, florid complexion, who, after menstruation 
had been obstructed for three months, was seized, on the 16th November, 1845, 
about 3 A. M., with a copious coloured discharge from the vagina without pain. 
When seen at 7 A. M., countenance pale ; pulse quick and weak ; discharge 
abundant, and mixed with coagula; uterus enlarged; os uteri flattened, and 
slightly open. The vagina was plugged, and sugar of lead and opium were 
given. The plug was removed in two hours by the nurse, on account of the 
uneasiness which it caused. On the 17th, the discharge, which had been 
abundant all yesterday, increased to-day, and was accompanied with large 
quantities of coagula; os uteri sufficiently open to admit the finger; the uterus 
seems full of coagulated blood. Under treatment the discharge abated, and in 
a few days she was so far recovered that Dr. Wood took leave of her. On No- 
vember 23d, he received a hurried message to see Mrs. C. in the evening, but 
being detained with a bad case of labour, did not see her until November 24th, 
at 7 A. M. He found that the bowels had not been open since the 25th ; had 
been complaining all day of stiffness of the jaws and sore throat, for which 
Dr. James Simpson, the family medical attendant, who had seen her in his ab- 
sence, had prescribed fomentations of chamomile flowers. The stiffness of the 
jaws was considerable, and they were opened with such difficulty, that it was 
impossible to see the throat; pulse 80, soft and compressible. In the forenoon 
the bowels were freely opened by a turpentine enema ; the stiffness of the jaws 
had, however, increased; acute pain in the spine was complained of; the abdo- 
minal muscles were stiff, and swallowing difficult. A sedative draught was 
now administered. On again visiting her in the evening, Dr. W. found that no 
relief had been obtained from the draught. She had had a tetanic spasm at 
P. M. ; and while visiting at 7 P.M., a second occurred. She could no longer 
swallow. Professor Syme was now consulted. Injections with tobacco, Indian 
hemp, and opium were prescribed, but the convulsions continued to increase 
in frequency, and she died at 10 A. M., on the 26th. 

In Dr. Malcolm's patient, tetanus supervened upon a severe attack of cynanche 
tonsillaris, with which the lady was seized upwards of a fortnight after she 
had suffered from abortion at a very early period of pregnancy, and from which 
she had satisfactorily recovered. When Dr. Malcolm was first called to see this 
lady she was suffering from inflammation and ulceration of the cervix, but had 
not the least suspicion of being in the family way. The treatment of this state 
of the uterus was commenced in the usual manner. In a few clays, however, 
she was taken with the symptoms of abortion, which speedily followed. In the 
course of about a fortnight, she had recovered so far that the usual daily visit 
was discontinued. About this time, having taken some liberty with herself, 
she caught cold. The cynanche tonsillaris was severe ; and on the second day 
it was accompanied, as often happens, with inability to move the jaw. On the 
third day, the symptoms were all very much aggravated, but presented no 
peculiarity. On the fourth day, she still continued very feverish and ill, and 
about noon she was seized, for the first time, with general tetanic spasms. 
She was seen in this fit by several physicians in the absence of Dr. M. When 
Dr. M. called the fit had ceased. After two hours the tetanic spasms returned 
with increased violence, and did not cease till she died, in the course of a few 

Dr. Simpson observed, that he had seen a patient die of tetanus after a 
uterine lesion, but not after abortion. In the case he referred to, and which 

248 Progress of the Medical Sciences. [July 

Professor Syme saw with him, a very large soft cellular polypus was detached 
and thrown off by the spontaneous efforts of the uterus. A few days subse- 
quently the patient had difficulty in opening her mouth. She died in the 
course of about fifty hours, with all the symptoms of general tetanus. In some 
of the Registrar-General's Reports on the Causes of Death in England, two 
cases of death from tetanus after child-birth are noticed. — Monthly Journal, 
April, 1850. 

57. Gangrene of the Vulva. By M. Monat. — Cases of this nature are not ex- 
tremely uncommon as occurrences after labour at the full time, but they are in 
the highest degree rare, at least in the adult, as cases of spontaneous disease, 
or as a consequence of abortion in the early months of pregnancy. 

A young woman, after a miscarriage, without any known cause, between the 
second and third months, was seized with violent inflammation of the labia. In 
spite of assiduous treatment with local emollients, leeching, &c, gangrene came 
on at the third day. The labia majora were both completely destroyed. The 
patient soon recovered. 

Sometimes this disease is epidemic. Such was the case in Lyons this winter. 
Six cases are recorded in the " Gazette Me'dicale de Lyon" where gangrenous 
ulceration of the vulva, vagina, or uterus came on after delivery. In 1815, and 
again, four years afterwards, the disease was epidemic in the Hopital de la 
Charite. — Gazette des Hopitaux, March 29, 1850. 

58. Puerperal Mania. — In a very interesting paper on the Mental Disorders of 
Pregnancy and Childbed, by Dr. F. Churchill, in the Dublin Quarterly Journal 
for Feb. last, the author briefly enumerates the following as the elements 
which may concur to produce an attack of puerperal mania : — 

" We have the nervous shock varying in degree, but always increasing the 
nervous irritability, the great vascular change, the disturbance of respiration 
and circulation, the exhaustion, and in many cases the loss of blood; this com- 
bination must necessarily leave the nervous system in a favourable state for the 
operation of the exciting causes I have enumerated, and the result is mania. 

" The treatment of puerperal mania," he remarks, " is very simple as regards 
the materials, yet requiring calmness and judgment in their application. 

"1. Those who regard it as any modification of phrenitis, of course recom- 
mend blood-letting, with more or less liberality. Now, from what I have said 
as to the nature of the disease, it will be clear that for these cases it is inad- 
missible, or, if ever used, it must be with extraordinary caution, and by means 
of leeches, in cases where there is strength and quickness of pulse, and flush- 
ing of the head and face. I have, however, never found it advisable ; and Es- 
quirol, Haslam, Gooch, Burrowes, and Pritchard, are all opposed to it. The 
last-named author remarks : ' If we consider that the greatest danger to be ap- 
prehended for patients labouring under puerperal madness arises from a state of 
extreme exhaustion, that many women die from this cause within a short in- 
terval from the commencement of the disease, and that, if they survive this 
period, the healthy state of the mind is in most instances restored, it will be 
evident that our chief endeavours must be directed to the present support of 
life.' ' Blood-letting, as a general remedy for puerperal madness, is condemned 
by all practical writers, on whose judgment much reliance ought to be placed.'* 

" 2. When the stomach is overloaded, when indigestible food has been taken, 
or even for the purpose of lowering the pulse by the shock of vomiting, emetics 
have been found useful. They must, however, be used with caution when the 
face is pale, the skin cold, and the pulse quick and weak. Dr. Gooch prefers 
ipecacuanha to antimonials. Dr. Burrowes recommends nauseating doses of 
tarter emetic, with the saline mixture and digitalis, for the purpose of reduc- 
ing the violence and fury of the patient ; and Dr. Beatty informs me that he has 
derived great advantage from tarter emetic. 

" 3. From the almost universally disordered state of the bowels, great relief is 
afforded by one or two brisk purgatives of calomel, followed by castor oil or 
Gregory's Powder. The stools are dark-coloured, and highly offensive ; and in 

* On Insanity, p. 313. 

1850.] Midwifery. 249 

addition to the advantage of clearing out the bowels, purgatives act admirably 
as derivatives from the head. 

" 4. After the bowels have been freed, the greatest benefit will be derived from 
narcotics. Denman prefers small and repeated doses of opiates, but Gooch, 
Burrowes, and Pritchard recommend full doses, and with this I concur : ten 
grains of Dover's powder, twelve drops of black drop, cr an equivalent of the 
other preparations of opium. If opium disagrees, hyoscyamus may be given ; 
and should sleep be induced, repeated small doses may be administered ; when 
the head is very hot, and face flushed, we should postpone the exhibition of 
opium, and we must guard against constipation. 

" 5. The head may be shaved, and a cold lotion applied ; if the delirium con- 
tinue, a blister may be applied, but it is not generally necessary. 

"6. In protracted cases, or when the patient is exhausted, nourishing diet, 
broths, &c, and even tonics, must be allowed ; ammonia, with cinchona ; oil of 
turpentine, &c. 

"7. As uterine inflammation not uncommonly arises in the course of, or fol- 
lows puerperal mania, a close watch should be kept for the earliest symptoms, 
and if they appear, calomel in small and repeated doses, or mercurial inunc- 
tion, should be added to the other remedies, with such other local applications 
as may be deemed advisable. 

"8. It will be necessary to keep the most careful watch upon the patient; the 
nurse, who ought, if possible, to be one familiar with such attacks, should 
never leave the room ; friends ought to be absolutely refused admission ; the 
apartment kept slightly darkened, and the entire house perfectly quiet. 

"9. When the mania disappears and the patient is convalescent, a change of 
air and scene is most advisable." 

59. On the Administration of Chloroform in Midwifery, and as a Sedative of 
Uterine Pain generally. By J. Henry Bennet, M.D. [London Journal of 
Medicine, March, 1850.) — The author states that his experience of chloroform, 
during the last two years, fully corroborates the opinions he formerly advanced 
favourable to the use of the article in irregular and operative labour, dysmenor- 
rhoea, and uterine pain generally. Dr. B. administers chloroform in four classes 
of cases : I. In irregular but natural labour. II. In operative labour. III. To 
facilitate operations on the uterus. IV. To subdue uterine pain in dysmenor- 
rhea, &c. In natural labour, Dr. B. seldom resorts to chloroform, unless it be 
occasionally to facilitate its last stage, or to allay some morbid conditions of 
the nervous and circulatory systems, which may be interfering with the pro- 
gress of parturition. The pains of labour are sometimes partially arrested, 
diminished, or rendered irregular and inefficient, by fear, impatience, want of 
self-control, or by long-continued suffering. When this is the case, chloroform 
generally exercises an all-but-magical efl'ect. Under its influence, all nervous 
excitement is soothed, the pains gradually become more regular, powerful, and 
efficient, and the labour once more progresses normally. This return of the 
labour-pains, and their regularization under the calming influence exercised by 
chloroform on the brain, probably explains the increase in their intensity, no- 
ticed by some writers, on its first administration ; and thus is explained the 
apparent discrepancy of different observers, on which so much stress is laid by 
the opponents to chloroform. If the pains are arrested or modified by nervous 
reaction, they return ; if, on the contrary, they are too violent and prolonged, 
as is sometimes the case in the latter stages of parturition, when the soft parts 
arc rigid and irritable, the intensity of the pains diminishes on the withdrawal 
of the excess of stimulation. 

The disordered state of the circulation, and the congested condition of the 
capillaries, which are often observed in the cases to which I have alluded, also 
give way, in a most remarkable manner, to the calm produced by the inhalation 
of chloroform. This is so much the case, that since I have had recourse to it, 
I have never found it necessary to bleed from the arm during labour ; the in- 
halation of chloroform having always been indirectly efficacious ; even in some 
cases in which the cephalic congestion was so great as to make me fear con- 

250 Progress of the Medical Sciences. [July 

When administering chloroform in simple midwifery, Dr. B. never gives it 
to such an extent as to annihilate pain, but merely so as to allay or deaden it ; 
in a word, he does not attempt to render the patient totally unconscious of her 
sufferings, but merely to render them bearable. In operative midwifery, the 
anaesthesia must necessarily be pushed further, that is, to the surgical extent, 
as the intention is then both to render the patient unconscious of what is done, 
and to obtain the muscular relaxation to which this stage of anaesthesia gives 

"At the same time," Dr. B. says, "although thus supporting the use of 
chloroform, I feel bound to repeat, that the fatal cases which have been pub- 
lished prove that its inhalation is not altogether free from danger to life. Nei- 
ther does it appear that this danger can be avoided by the greatest caution ; 
death having followed, as I have already stated, the administration of an in- 
significant dose in the hands of experienced practitioners. It would indeed 
seem as if, in the cases to which I allude, chloroform had acted as a deadly 
poison from the first moment of inhalation. These cases must, therefore, teach 
us not to resort to it without a good and sufficient reason, and not to urge it on 
unwilling patients. For my own part, I am perfectly prepared in my own 
person, again to run the risk, such as it is, should I be again called upon to 
suffer a painful operation ; and, consequently, I feel no hesitation in giving it 
to any one else who, like myself, may wish to avoid pain at a very trifling risk. 

"We must not forget, however, that the dangers of chloroform inhalation have 
only been exemplified in surgical cases, and that no parturient woman has died 
during, or from its administration. They are, in reality, less exposed than sur- 
gical patients, as anassthesia need not be carried so far ; moreover, the entire 
economy is during labour in such an increased state of stimulation, that the 
vitality of the patient would, I think, be much less easily subdued, than in one 
who is depressed by the dread of a surgical operation." 

60. Insanity from the Use of Chloroform. — In our preceding Number, p. 529, 
we noticed a case of insanity from the use of chloroform during parturition, com- 
municated to the Westminster Medical Society, by Dr. Webster. Three simi- 
lar cases were related at a previous meeting by the same gentleman, and we 
now give the report of them : — 

Case I. — In this instance the patient, who had been delivered under the in- 
fluence of chloroform, was, for three days subsequently, constantly incoherent 
and rambling. She soon after became perfectly maniacal, and so furious as to 
require confinement in a lunatic asylum, where she remained for twelve months, 
when the lady was discharged, cured. 

Case II. — This patient never recovered from the effects of the chloroform 
exhibited during her confinement ; and soon afterwards became quite maniacal, 
and continued so for many months, but she recovered ultimately. 

Case III. — As this example might perhaps be considered by some psycholo- 
gists not a true instance of insanity, Dr. Webster related the chief symptoms 
manifested by the patient, in order to remove all doubts on the subject. In 
the case reported, the cerebral disturbance following the exhibition of chloro- 
form during delivery, never ceased entirely ; the patient could not sleep at 
night for a long time, and often said she felt as if in the presence of a madman 
who was going to murder her. Three weeks afterwards she became almost 
maniacal — exhibited much mental excitement, laughing frequently ; had a 
strong desire to sing, with other extraordinary feelings ; conducted herself like 
an infant, and lost her memory ; in which state the patient continued during 
five months, when recovery took place. — Psychological Journal, April, 1850. 

61. A Series of Cases Illustrating the Contagious Nature of Erysipelas and of 
Puerperal Fever, and their Intimate Pathological Connection. — A communication 
was read to the Edinburgh Obstetrical Society (Jan. 9, 1850), from Dr. Hill of 
Leuchars, detailing a series of cases of erysipelas, and of puerperal fever, which 
illustrated very strongly the intimate pathological connection between these 
two diseases. From the cases related, it was evident that the same poison, 
whatever was its nature, might cause ordinary erysipelas in some subjects, and 

1850.] Midwifery. 251 

puerperal peritonitis in child-bearing women, when they were exposed to its 

In the month of June, 1848, a carpenter in the village of Leuchars, wounded 
his hand while making a coffin ; and subsequently, when putting the corpse 
into it, he felt some fluid from the body come in contact with the wound in his 
hand. In a few days the hand swelled up, and a severe attack of erysipelas 
ensued. Soon afterwards, his wife was taken severely ill with a similar attack 
in the right hand and arm. Both of them ultimately recovered. During their 
illness, however, their daughter, a young servant girl, in the seventh month of 
pregnancy, and who had come to their house to be confined, was seized with a 
feverish attack, for which I prescribed. On my way home, after visiting this 
girl, I was called to a woman in labour, who was confined in the course of two 
hours. Next morning the servant girl (the carpenter's daughter) was taken 
with labour, and soon gave birth to a dead child, whose body had all the appear- 
ances of being affected with the same disease as the arms of the mother's 
parents previously were. She herself never rallied after delivery, but died in 
the afternoon of the same day, with all the symptoms of malignant puerperal 
fever. I immediately informed the friends of the woman whom I had delivered 
the day previously, that I should not again visit her, unless serious symptoms 
came on, demanding my attendance. On the third day after her delivery, I 
was sent for, and found her labouring under puerperal fever. She, however, 
gradually recovered under treatment. 

On the 30th August, 1849, I was called to see a girl, eight years of age, 
affected with erysipelatous inflammation of the skin of the right parotideal re- 
gion. The gland itself was considerably swollen, and there was slight fluctua- 
tion in it. After being fomented for a few days, a large quantity of matter 
was discharged. 

On the 8th September, I was sent for to Mrs. F., the mother of this child, a 
strong healthy womon, set. forty-five, and nearly at the full period of pregnancy. 
I found the glands at the angle of the jaw slightly swollen, and some erysipelas 
spreading from over them to the ear. The treatment instituted had no effect. 
On the morning of the 10th, however, labour commenced, and the erysipelas 
entirely disappeared during its progress. The infant was born in the course 
of the afternoon, having its face and forehead completely covered with erysi- 
pelas. After two days the erysipelas disappeared ; but again, a week after- 
wards, it commenced at the vagina, and gradually spreading over the abdomen, 
carried off the child in a short time. On returning to see the mother on the 
morning after her delivery, I found that the erysipelas had again returned with 
violence, over the whole face, which was very much swollen. There was no 
symptom of peritoneal inflammation. I immediately put her under a course 
of mercury, ordered a laxative draught, and hot fomentations to the erysipela- 
tous parts, &c. &c. The fever continued severe for a few days, but she ulti- 
mately did well. 

The midwife, who, on the 10th September, attended Mrs. F., was called on 
the following day to wait upon a servant girl, who had come to her father's 
house to be confined. A healthy child was born. The mother continued to 
do well till the fifth day, when she had a fit of shivering, was seized with pain 
in the head, and became feverish. Subsequently, she became affected with 
most violent diarrhoea, from which she ultimately recovered. 

The father of this girl, an infirm old man, watched over her anxiously for 
three days of her illness, when he himself was seized with a fit of shivering, 
and became feverish. He complained much of pain in the throat, and difficulty 
of swallowing. The fauces and palate were of a deep red colour, and there 
was considerable swelling at the right side. Next day the right parotid gland 
was much swollen, and an erythematous blush appeared over it, which gradu- 
ally increased to erysipelas of the whole face. The accompanying fever was 
of a low type, and in spite of the assiduous administration of stimulants, the 
poor man sunk on the ninth day of the attack. 

Another daughter of this man, who had been in constant attendance on him 
and her sister, was seized with erysipelas, commencing at the ankle, and spread- 

252 Progress of the Medical Sciences. [July 

ing upwards as far as the knee. Under some simple treatment she rapidly re- 

The midwife, who had been in attendance on the two cases of labour just 
related, was, on the 16th September, herself seized with shivering, and the 
right arm became painful and very tumid. On the third day the glands in the 
axilla were much swollen up and inflamed. Leeches and hot fomentations 
were applied, and gave considerable relief; but an abscess formed and was 
opened. She soon recovered. 

In the end of September, the nurse who took care of Mrs. F. after the mid- 
wife had left her, was taken ill on the third day after Mrs. F.'s confinement. 
She was seized with shivering and pain in the middle finger ; afterwards, on 
visiting her, I found the veins of the forearm inflamed, the course of each 
vessel being traceable by a deep red line. After a short time violent erysipe- 
las commenced at the hand, and extended up the whole arm. Matter was 
formed and discharged in great quantity through deep incisions which were 
made in the arm. She ultimately recovered. 

The woman who attended this last patient was seized with shivering and 
sore throat. On examination, the fauces were found of a deep red colour, and 
the glands much swollen, but not inflamed. The accompanying fever was of 
a low typhoid type. This woman also ultimately recovered. — Monthly Journal 
of Medical Sciences, March, 1850. 

62. Inflammation of the Mammae. By Mr. T. W. Nunn. — After a few remarks 
on the common modes of treatment of inflammation of the mammary gland, 
and their inadequacy to prevent suppuration, the author stated that he proposed 
the following plan. 1. To confine the patient to the horizontal position. 2. To 
prevent any extraneous irritation of the inflamed organ. 3. To envelop the 
breast with mercurial ointment spread on thin linen, and to cover this with a 
tepid poultice. 4. To support the gland by a suitable bandage, when the hori- 
zontal position cannot be maintained. 5. After the constitutional irritation 
has been allayed by a brisk purgative, effervescing salines, and proper regimen, 
to carefully watch the state of the pulse, and look for the proper moment for 
the administration of tonic medicines. 6. Wine and stimulating articles of 
diet should be allowed only with great caution. In the majority of cases, Mr. 
Nunn was of opinion that, after the first day or two, the patient needs bark 
and ammonia, quinine and iron, rather than depletive drugs. The strength of 
the mercurial application should be adapted to the condition and natural tex- 
ture of the skin covering the gland. In some instances, the unguentum hy- 
drargyri fortius will not be found too powerful ; in others, it will be necessary 
to dilute it with an equal proportion of ceratum resinse. A combination of the 
extract of belladonna, hyoscyamus, or opium, in the proportion of £i to the ^i 
of ointment, will be most effectual in allaying the intense agony frequently 
complained of. The leading idea in treating mammary inflammation, should 
be the prevention of suppuration ; when that cannot be avoided, the attempt 
should be made to render it as circumscribed as possible. Mr. Nunn opposed 
large incisions of mammary abscesses, and thought the practice of laying open 
extensive sinuses of the breast uncalled for. The tissue of the gland, he 
averred, should not be cut ; and he quoted Dr. Gibson, of Philadelphia, to show 
that sinuses may be obliterated by pressure. The importance of preserving 
the integrity of the gland, he (Mr. Nunn) observed, cannot be overrated. He 
related several cases in illustration of his position. 

Case 1. A young woman, aged twenty-two, who had been confined with her 
second child about a month, applied to Mr. Nunn, with her breast in a state of 
intense inflammation. She had been applying poultices and hot fomentations 
for two or three days, without any relief. Her tongue was white ; bowels con- 
fined ; much thirst; pulse rapid, but weak; skin moist. She was ordered a 
saline aperient of magnesia, and a drachm of decoction of cinchona twice a 
day ; also to have mercurial ointment, diluted with resin cerate, applied to the 
breast. In ten days, the redness, heat, and swelling, had much diminished, 
and the constitutional symptoms were improved. The ointment gave great 
ease, and had enabled her to sleep ; it had not produced any unpleasant effects. 

1850.] Midwifery. 253 

She was ordered to apply the ointment more sparingly, and to take quinine 
and porter. In a few weeks, the disappearance of some hardening which had 
remained indicated a satisfactory termination of the case. 

Case 2. M. R., aged thirty-nine, had chronic inflammation of the right breast, 
for which she had been subjected to a variety of treatment. The swelling was 
principally confined to the lower half of the oxgan ; there was little redness, 
but much tenderness. Mr. Nunn ordered mercurial ointment, with a drachm 
of opium to the ounce, to be rubbed in, and the patient to take ammonia, with 
cinchona and conium. The ointment gave rapid relief, and the patient soon 

Case 3. M. M., aged twenty-one, applied to Mr. Nunn, about six weeks after 
delivery, with an acutely inflamed breast. The mercurial application was 
ordered. She neglected to report herself at the time appointed, but applied 
the ointment for a week. The system became affected, but no actual mischief 
appeared to have been done. This was the only case in which the mercurial 
application had effected more than was desirable ; and though suggesting cau- 
tion in its employment, Mr. Nunn did not consider that it formed an objection. 

Case 4. M. A., aged forty, had mammary abscess, which had been treated 
by poultices, etc. It had burst, and left a circular ulceration of the size of 
half-a-crown. The granulations on the surface of the gland were weak and 
flabby, and covered with a copious secretion of pale pus. Mr. Nunn discovered 
a large flat sinus, extending a considerable distance deyond the margin of the 
ulcer ; the discharge from it was very abundant, and depressing to the patient. 
The poultices were discontinued ; bark and ammonia were administered, with 
a more generous diet. The sinus healed without the necessity of laying it 
open, and the patient was restored to health. 

The author pointed out the importance of attending to the peculiar relation 
in which the mammary gland stands to the economy, and to the effects pro- 
duced by inflammation of the trabecular and of the secreting structures. It is 
important to the mother, as well as to the child, that the integrity of the organ 
should be maintained. Mercury, in virtue of its efficacy in checking the tend- 
ency of blood to deposit fibrin, and of its property of causing the reabsorption 
of effused lymph, seems to be strongly indicated in the disease under considera- 
tion. Its benefit is obvious, when we reflect that by the formation of an abscess 
in the substance of the gland, the ducts are destroyed, and the portion of the 
gland becomes isolated. For a time, it may give no inconvenience ; but, under 
the excitement of lactation, it may become the seat of a fresh attack of inflam- 
mation. This, Mr. Nunn observed, must have been met with by every practi- 
tioner of experience. In conclusion, Mr. Nunn said that he would not be 
understood to advocate the use of mercury in all cases of mammary irritation, 
but he believed the plan he had recommended likely to prove of great service. 

Mr. I. B. Brown said, that one great cause of inflammation of the breast 
was, the not applying the child to the breast early enough. This cannot be 
done too soon after delivery. Stagnation of the milk in the breast acts as an 
irritant, and causes inflammation. It can be overcome by general remedies— ■- 
the horizontal position, keeping the breast supported, causing the skin to act,. 
and by warm-water dressing. He objected to drastic purges. Parturient 
women cannot bear to be lowered, and ought not to be subjected to the de- 
pressing action of mercury. Mammary inflammation was often caused by 
keeping the patients on gruel, when they required an improved diet. The 
excess of fluid was bad. Most patients subject to inflammation of the breast 
were of the strumous diathesis, and could not bear mercury, which would de- 
teriorate their milk and injure their offspring. Mercurial ointment might be 
useful in chronic mammary inflammation, but it could not be used with safety, 
he thought, in an acute attack. 

Dr. Murphy said that no One plan of treatment could be followed as the 
best in all cases of inflammation of the mammae. Mammary abscess might be 
sthenic or asthenic. In strong, healthy young women, where the milk, from 
some cause, was not withdrawn, he was satisfied that, if proper antiphlogistic 
measures were adopted, there would be no reason to fear abscesses forming. He 
advised the combination of tartar emetic with the neutral salines. The feelings 
No. XXXIX.— July, 1850. 17 

254 Progress of the Medical Sciences. [July 

of the patient should be consulted as to the use of warm or cold applications. 
In weak and irritable women, if purgatives and tartar emetic were used, the 
irritation would be increased, and abscess after abscess would form. Such 
patients require tonics and support. If, on the other hand, a robust, plethoric 
woman be placed on full diet, after parturition, mammary abscess will be very 
apt to occur. 

Dr. Manson stated that at the General Lying-in-Hospital it had been the 
custom for the last twenty years, when the breast became hard and knotty after 
parturition, to rub in freely the linimentum ammoniae, as.a preventive of sup- 
puration ; and so successful had this practice been, that they had scarcely ever 
had a case of mammary abscess.* The liniment is rubbed in for ten minutes 
or a quarter of an hour, until the breast becomes soft and supple. He thought 
it acted as an emollient and evaporating lotion, while the stimulant quality of 
the ammonia was evidenced in the reduction of the quantity of the milk. 
When the inflammation is so severe that friction with the liniment cannot be 
used, he thought the mercurial ointment might be tried, with a poultice over it. 
In a very severe case, chloroform was given before friction was used, and suc- 
cessfully ; the patient recovered without suppuration. — London Journal of Medi- 
cine, March, 1850. 

[We have for many years employed fomentations with vinegar and water, as 
recommended by Dr. Dewees, followed by gentle friction with olive oil or cam- 
phorated oil, and have found it a perfectly successful mode of treating inflam- 
mation of the mammary gland. — Editor.] 

63. Diagnosis between Real and Apparent Death in Newly-born Children. — It 
is well known how difficult it is to determine whether a child born in a state 
of asphyxia be really dead. If the pulse be not perceptible, if respiration be 
absent, and if the beating of the heart be not heard, it is sufficient to lead most 
accoucheurs to decide that the child is born dead, and to decline making any 
attempt at artificial respiration — too probably fruitless. It would be important 
to possess a certain sign thjit life still existed, even though all its functions had 
apparently ceased. M. Van Hengel thinks he has discovered such a sign. 

In May, 1848, he administered ergot of rye to a patient labouring under 
hemorrhage. The hemorrhage was arrested ; but the infant was born appa- 
rently dead. There was no respiration ; the hot bath was first tried, then al- 
ternate immersion in hot and cold water. Tickling of the nostrils also pro- 
duced no result. M. Van Hengel thought of stimulating the sacral nerves by 
means of a stimulant enema. Having no syringe at hand, he took in his mouth 
a mixture of brandy and cold water, and blew it into the anus through a pipe. 
He then removed the pipe, and retained the liquid in the rectum for a few se- 
conds by means of his finger. Three or four seconds after he removed it, the 
liquid was forcibly ejected, mixed with meconium. This experiment made 
such an impression on the parents, that though they had previously thought it 
unnecessary to have the child baptized, they now had that ceremony performed 
without delay. It was not possible to further reanimate the child ; and a mix- 
ture of brandy and water injected half an hour after flowed out immediately. 

In subsequent experiments on the dead body, the liquid either returned im- 
mediately, or remained in the interior. M. Van Hengel hence thought himself 
authorized to suppose that by the use of the stimulant injection, the nerves of 
the rectum had been acted on so as to produce expulsive action ; and that this 
denoted that life still remained. 

It might, however, be objected that the expulsion of the enema was due to 
the contractile power of the intestines remaining some time after death ; and 
that, to give any importance to the sign adduced by the author, it would be 
necessary to perfectly resuscitate a child, in which this sign alone denoted the 
existence of life. M. Van Hengel has had the good fortune to do this ; and the 
following case will be read with interest. 

Case. Madame B. was delivered of a female child, by the natural efforts, 

* A more common, and, so far as our experience goes, an equally successful method, 
is frequent gentle friction with warm olive or other bland oil. — Editor. 

1850.] Midwifery. 255 

after a labour of two hours, during which symptoms produced by shortness of 
the umbilical chord were perceived. This was twisted round the neck of the 
child, and pulsated very feebly ; the infant did not cry ; the skin was bluish, 
and the limbs tolerably firm. The cord was immediately cut, and about a tea- 
spoonful of blood expressed from it ; the child was placed in a warm bath, after 
which a little more blood flowed. M. Van Hengel then injected an enema of 
brandy and water; this was ejected in three minutes, in an arch form, with me- 
conium. The infant was baptized ; and air was blown into the mouth, the nos- 
trils remaining open. This was done very cautiously at first, but soon with 
more force, and with the mouth of the operator applied to that of the infant. 
After a little time, the thorax dilated ; pressure was now made on the ribs, 
and it was thought that the infant performed a share of the movements there- 
by produced. This operation was continued for three-quarters of an hour. Al- 
ternate hot and cold baths were again tried ; a spasmodic respiration seemed 
to set in, but at long intervals. As this diminished in intensity, an attempt 
was made to produce vomiting, so as to cause a deep inspiration, by tickling 
the palate and tonsils with a feather. The desired result was obtained ; the in- 
fant made a deep inspiration, but without crying ; and it was necessary to press 
the abdomen and thorax to produce expiration. On endeavouring to repeat the 
experiment, the mouth was found spasmodically closed, and it was necessary 
to introduce the feather into the nostrils. This induced a tendency to sneezing ; 
and a strong expiration took place. This circumstance suggested a means ofj 
producing, at pleasure, inspiration and expiration. 

The barbs of a feather were cut, so as to leave them about three centimetres 
long at the end ; the stem was then stripped off them for four orfive centimetres, 
and beyond this they were left. On introducing the feather into the nose, the 
tickling of the nostril produced an effort at sneezing, and consequently an ex- 
piration ; when the feather was carried as far as the velum palati, there was an 
attempt at vomiting, and consequently an inspiration ; when it was carried 
still further inwards, the last barbs of the feather tickled the nostril, while the 
others only provoked an effort at deglutition. By alternately introducing and 
withdrawing the feather, efforts of inspiration and expiration were produced 
in succession. This process was continued for half an hour. 

At the end of this time, the operation was suspended, because the infant lost 
some blood by the nose. The object, however, had been gained; the child was 
alive, and cried. The next day, a teaspoonful of syrup of marsh-mallows was 
administered to it. Everything went on well; and the child continues to en- 
joy health. 

Such a fact as this is sufficiently important to call for a series of analogous 
experiments on a large scale. Practitioners should especially not lose sight of 
the ingenious means employed by M. Van Hengel to promote a kind of respira- 
tion at once natural and artificial, which may be substituted, at least at first, 
for the always difficult process of insufflation. — London Journ. Med., Feb., 1850. 

64. Discussion in the French Academy of Medicine upon Engorgements of the 
Uterus. — The presentation of a report, in October, by M. Ilervez de Chegoin, 
upon a memoir upon "Deviations and Engorgements of the Uterus," forwarded 
to the Academy by M. Baud, has given rise to a more animated and prolonged 
discussion than has recently occurred in that body. This has been remarkable, 
not only from the great diversity of opinion prevailing among equally high 
authorities, and that on matters apparently capable of physical demonstration, 
but also from having brought into the field some eminent men (as Paul Dubois, 
Jobert, Recamier), who very rarely take part in the discussions at the Academy. 
To our view, the discussion is also of importance as promulgating a recantation 
of a dangerous medical heresy. How short is the period since, when under the 
influence of Lisfranc's views, half the women of Paris were condemned to abso- 
lute recumbency, debilitating depletion and regimen, and in many instances to 
cruel operations, under the belief they were suffering from inflammatory affec- 
tions of the uterus, tending in numbers of cases to cancerous degeneration ! 
Whatever the difference of opinions offered in the present discussion, however 
opposite these may be, all now unite in repudiating as untrue in fact, and 

256 Progress of the Medical Sciences. [July 

dangerous in practice, the doctrines received so short a time since "with such 
confidence, and acted upon with such dangerous vigour. In this country they 
were received with little favour ; and the remembrance of their extravagance, 
and of their discomfiture in their natal soil, may account for the distrust which 
is now felt at the attempts recently made to instal ulceration and other affec- 
tions of the cervix uteri as the dominant cause of female ailments. 

Of a discussion that has occupied so many sittings, we can only profess to 
furnish an outline, reserving all appreciation and criticisms of the opinions 
advanced for future consideration in another department of the journal, as 
opportunity may offer. 

M. Baud regards the diseases of the uterus from an exactly opposite point of 
view to that taken by Lisfranc, believing that both they and the deviations of 
the organ from its normal position are for the most part due to a disordered 
state of the general economy, in which the uterus participates, and on the relief 
of which these secondary and passive effects disappear. He concludes: 1. That 
all treatment which ameliorates the general condition is a step towards the 
cure. 2. Treatment ameliorating the local condition, to the detriment of the 
general, aggravates the disease. 3. Treatment should be adopted under the 
idea that the uterus is in a passive and mechanical condition. The remedies 
he recommends to carry out these views are of a tonic and corroborant kind, 
whether locally applied or given internally. 

M. Hervez de Chegoin, reporting on this paper, while regarding the opinions 
advanced in it as too exclusive, yet states his belief that the local uterine affec- 
tions are most aptly treated by general means, and that the engorgements ob- 
served in displacements of the uterus are often only the results of these, and 
disappear when the latter have been rectified. While he blames Lisfranc's in- 
discriminate treatment, he cannot admit that inflammatory engorgements in- 
quiring leeches may not sometimes exist; while, moreover, local engorgements 
may occur quite independently of a disorder of the health, the woman being 
otherwise quite well. In passive engorgement, too, dependent upon displace- 
ment, all internal treatment is useless without mechanical aid, which indeed 
M. Baud admits is then also sometimes required. M. Baud also attributes 
leucorrhoea to general debility, calling for tonics and astringents ; but while it 
may be admitted that a tonic treatment best accords in general, there are other 
cases in which the mildest procedures are alone admissible. Every one has 
seen examples of obstinate yellow discharges, with a tendency to constriction 
of the vagina, and the production of painful fissures ; which, though indolent as 
long as no physical cause of irritation exists, are exasperated by all tonic and 
astringent applications, and yield only to the mildest, of which distilled water 
forms one of the best. In other cases, in which there is an altered, thickened, 
or granular state of the lining membrane, neither tonics, nor emollients, nor 
any internal treatment are of avail, until the condition of this be changed by 
special applications. Leucorrhoea, too, resulting from uterine neuralgia, calls 
also for its special treatment. 

M. Gibert: While practitioners of the olden times regarded the uterus as a 
kind of critical and depuratory emunctory, whose lesions depended in general 
upon a general diathesis, those of more modern times have been too much 
accustomed to make it the point of departure for the most varied and most 
serious general accidents, counselling for what were most trifling ailments 
the most active procedures, and leading those who had little the matter with 
them to believe themselves dangerously ill. Such alarming statements, in 
fact, were the means of generating in those to whom they were addressed a 
series of general symptoms, pains, and disturbances of function, attributed 
to the disease, but which disappeared when these persons were subjected to a 
more rational treatment, and their minds tranquillized. A large hospital prac- 
tice, in which constant examinations of the organs have been made, enables 
M. Gibert to assert: 1. That the alterations in colour, form, volume, texture, 
and situation of the neck of the uterus, signalized by so many surgeons as 
the point of departure and origin of such varied morbid phenomena, may be 
discovered without their having given rise to any of the ill consequences so 
frequently attributed to them ; and, 2. The various symptoms, signalized by 

1850.] Midwifery. 257 

Lisfranc as the necessary accompaniments of engorgement, may occur without 
any sensible alteration in the cervix being discernible. Believing, however, in 
the existence of such a disease as engorgement of the' cervix, he regards it as 
almost always an effect of a lymphatic diathesis, and one of the consequences 
of delivery. 

M. Velpeau excited numerous replies by maintaining that engorgement of the 
uterus, as an affection independent of inflammation, had no existence; and 
although he limited this exclusion afterwards to the body of the uterus, yet even 
as regards the cervix, he maintained it is comparatively a rare affection, and 
one for which inflexions of the organ are frequently mistaken, these being of 
far more frequent occurrence than is generally believed. Lisfranc maintained 
that inflexions were only the consequences of engorgements; but M. Velpeau 
declared that, when hypertrophy exists, it is the consequence of the inflexion, 
and it is indeed always found on the side of such inflexion. Pessaries have 
been much misused ; of service in simple deviation, they are of no service when 
the womb is inflected, and the abdominal bandage is then the only thing M. 
Velpeau has found act as a palliative. M. Velpeau believes that neither author 
nor reporter attaches a sufficient importance to local remedies, although he 
agrees with them as to the importance of general treatment in certain cases. 
The white discharges from the cervix result either from carcinomatous diseases, 
or from the presence of granulations or vegetations in the parts, which is in- 
deed the commonest of causes of uterine discharges, and can never be efficiently 
treated without local means, of which the acid nitrate of mercury is by far the 

M. Malgaigne believes, with M. Velpeau, that many of the uterine affections 
are local, and call for local remedies, but he thinks that the frequency of ulcer- 
ation has been exaggerated. The reporter declares retroversion a much more 
frequent deviation than anteversion; but M. Malgaigne, while engaged at the 
Bureau in the application of pessaries, could never meet a case of retroversion, 
though examples of anteversion were frequent; but while this discussion was 
going on, no less than three examples of the former came under his notice, be- 
cause, as M. Dubois declared, he had proceeded with the view of searching for 
them. As a local application in the engorged cervix uteri, he prefers the actual 

M. Moreau considers M. Velpeau's assertions far too general; for, because 
ignorant persons may mistake displacements for engorgement, it does not follow 
this may not exist. As M. Velpeau stated cadaveric proofs were wanting, he 
would cite an example on the living; for, a uterus having been removed on sup- 
position of carcinoma, its body was found simply engorged. Engorgement of 
the cervix is of far more frequent occurrence. Contrary to M. Malgaigne, he 
believes that anteversion is very rare, and retroversion of the non-pregnant 
uterus is far more frequent. 

M. Jobert considers that engorgement of the uterus may exist either as symp- 
tomatic of other affections, or idiopathically, and in this last case demanding 
local applications, as its principal, if not as its sole treatment ; and it is here 
that he has found the actual cautery so valuable. Deviations of the uterus may 
be either congenital or acquired. In the first, the uterus undergoes a change 
in its proper texture, an atrophy or imperfection of development occurring in 
the direction of its curve. Such changes in form may produce no accidents 
until puberty, and none at all unless menstruation is impeded by them. These 
congenital deviations are irremediable by art ; and while those arising acci- 
dentally may be remedied, they cannot be so by local means alone, dependent 
as they are upon an altered condition of the tissues, which must be restored to 
their normal state, mechanical means being used only as auxiliaries. 

M. Robert entered into a long dissertation to show that the symptoms attri- 
buted to engorgement were really due to a granular state of the lining membrane 
of the cavity of the uterus, long since pointed out by Recamier, and that on 
scraping these away (examined microscopically, they appear to be mere expan- 
sions of the proper texture of the membrane), and afterwards applying caustic, 
the symptoms soon yield. 

M. Huguier, in answer to M. Velpeau's challenge to exhibit engorgement in 

258 Progress of the Medical Sciences. [July 

the dead body, observed that, as in engorgements of other tissues, these rapidly 
disappeared after death, and that he had repeatedly measured the cervix before 
and soon after death, and found it diminished afterwards by more than a third. 
Nevertheless, he exhibited preparations to the Academy, which were generally 
acknowledged to demonstrate the engorgement in question. Of 2527 cases of 
which he has kept notes, at the Lourcine and Beaujon, he finds there were 131 
well-marked examples of engorgement; and of these, in 106 it affected the cervix 
alone, 8 the body and cervix, 13 the body alone, and 4 remained unindicated. 

M. Roux observed that engorgement may be affirmed from analogy and patho- 
logical anatomy. Thus, when we see the orifices of the mucous canals, the 
amygdalae, spleen, liver, &c, liable to become engorged, it would be strange if 
an organ like the uterus, having abundance of vessels, and a periodical flux, and 
fulfilling functions often giving rise to irritation, should be exempt. Twice M. 
Roux had been induced to extirpate the uterus ; in the one case cancer was far 
advanced, and hoping in the other to remove the organ in an earlier stage, it 
was found quite unaffected with organic disease, being simply engorged. A 
member inquired "What became of the patient?" M. Roux's solemn reply 
" obiit," coupled with the assurance that no consideration would induce him to 
undertake again this operation, ought to have conveyed a wholesome lesson to 
his younger auditors. 

M. Hervez de Chegoin observed that anteversions are of more frequent occur- 
rence than retroversions, because the latter require in general a peculiar excava- 
tion of the sacrum for their production ; but they give rise to less inconvenience 
than retroversions, being but an exaggeration of the natural position of the 

M. Amussat believes that, while Lisfranc much exaggerated the frequency of 
engorgement, it would be a great error to deny its existence, or attribute it 
entirely to the operation of deviations, as also to refuse to admit that the affec- 
tions of the uterus may exert a great effect on the system at large. In treating 
engorgement, if general measures are found insufficient, we must also resort to 
local ones, and not wait too long before we do so. Cauterization, if perse- 
veringly used, is an excellent means, and even may be of avail in cancerous dis- 
ease ; for this is more amenable here than in the breast, and less liable to re- 
lapse. He prefers the solidified potass and lime to the actual cautery, but 
recommends it to be freely applied. He believes that both anteversion and 
retroversion occur more frequently than is allowed, and the one perhaps as 
often as the other, although retroversion, by its greater importance, has attracted 
more attention. He has succeeded in curing some cases by cauterizing the 
posterior surface of the cervix, and getting this to adhere to the opposite wall 
of the vagina. 

M. Recamier, the originator of the modern pathology of uterine disease, de- 
livered a discourse tending to demonstrate the reality of uterine engorgement, 
which he regarded of an erectile nature, exactly analogous to erectile engorge- 
ments about the rectum. 

M. Paul Dubois delivered a most able address upon the subject, reviewing the 
opinions of the former speakers, and communicating his own in a most lucid 
manner. The length of his address, and the importance of the numerous facts 
and observations it contains, oblige us to defer our analysis of it until our next 
number. — British and Foreign Medico- Chirurgical Review, April, 1850, and 
Gazette Midicale, 1849, Nos. 41—47; and 1850, Nos. 3—5. 

65. On the alleged frequency of Ulceration of the Os and Cervix Uteri — Specu- 
lum Practice. — Dr. Tyler Smith read a valuable practical paper on this subject, 
before the Westminister Medical Society, April 6th, 1850. This paper has 
since been published {Lancet, April 20th), and from this publication we make 
the following abstract : — 

Mr. Whitehead, of Manchester, in his work on " Abortion and Sterility," 
states that, of 2000 women whose cases he investigated on their application to 
the Manchester Lying-in Hospital, " 1116 had the whites at the time the inquiry 
was made, and a considerable number more had suffered under a similar ailment 
at some former period. In 936, or eighty-three per cent., the discharge bore 

1850.] Midwifery. 259 

undoubted evidence of the presence of pus, or of sanies ; and in some instances 
it was more or less mixed with blood." Mr. "Whitehead traces these discharges 
to "disease of the lower part of the uterus, this disease being found to exist in 
almost every instance;" and he further declares that " this lesion of structure 
constitutes the true pathological seat of leucorrhoea, and of all its associated 
phenomena." Dr. Henry Bennet states, in his recent work on "Inflammation 
of the uterus and its appendages, and on ulceration and induration of the neck 
of the uterus," that of 300 cases presenting " uterine symptoms," among the 
patients of the Western dispensary, he found that " 243 were suffering from de- 
cided inflammatory disease of the cervix or its cavity ; and that in 222 ulceration 
was present." Thus in Mr. Whitehead's cases, in 936 out of 1116 cases of leu- 
corrhoea, the discharge was purulent or ulcerative ; and in Dr. Henry Bennet's 
cases, 222 out of 300 or more than two-thirds, were also suffering from uterine 
ulceration. Dr. Bennet states that the same proportions are preserved in the 
cases he has treated in private practice. 

It is well known that this is widely at variance with the experience of pre- 
vious observers in this country. Does this discrepancy arise from the superior 
modes of investigation adopted by the authors I have quoted, or does it happen 
from some misapprehension as to what really constitutes ulceration of the os 
and cervix uteri ? Is there simply some mistake about the nature of ulceration, 
or is the difference explained by the more general use of the speculum ? 

Practising as a physician-accoucheur, I must get the same class of patients 
as those treated by Mr. Whitehead and by Dr. Bennet. I am in the habit of 
using the speculum in cases of obstinate leucorrhoea in married females, and I 
trust with a desire to observe truly and faithfully, but I do not myself find 
uterine ulceration — at least not what seems to me to warrant this term — so fre- 
quently as Dr. Bennet, Mr. Whitehead, and some other gentlemen who have 
written upon the subject, in leucorrhoeal cases, purulent or muco-purulent. I 
find inflammation, engorgement, induration, excoriation, patches of aphthae, 
epithelial abrasion, and granulation often enough, but very seldom what I 
could call ulceration, in non-malignant and non-syphilitic cases. 

After giving a quotation from Dr. Bennet' s description of ulceration, Dr. 
Smith says : — 

If we consider excoriation or abrasion as genuine ulceration, probably no 
woman ever passes through life without suffering from this form of disease. In 
the virgin uterus, the circulation is frequently modified by the recurrence of 
menstruation, ovarian irritation, mental emotion, the varying condition of the 
bladder and rectum ; and in constitutional ailments, the vaginal and uterine 
secretions, in common with the other secretions of the body, are frequently 
depraved. Excoriation and abrasion of the mucous membranes are easily ac- 
counted for under such circumstances. Menstruation alone in the turgidity of 
the uterus and ovaria, before the catamenial flow is established ; in the exuda- 
tion of blood from the surface of the uterus ; and in the perforation of the peri- 
toneal membrane for the elimination of the ovule from the ovary, trenches very 
nearly upon pathology. The slightest divergence from the ordinary function 
merges into disease. 

In married women, and those who have borne children, other prejudicial 
causes in addition to these are in operation : such are the mechanical irritation 
of coitus, the risk of lacerations of the os uteri during the passage of the child 
in parturition, and the state of the uterine orifice which obtains after labour, 
and the return of the organ to quiescence. After labour, the orifice of the 
uterus does not contract smoothly, so as to leave the os uteri regular and even, 
but it becomes puckered and contracted unevenly. In irritable conditions of the 
mucous membrane of the uterus and vagina, or in a morbid state of the utero- 
vaginal secretions, these folds or corrugations are very liable to be chapped or 
excoriated, and I believe this is often mistaken for ulceration. All these, and 
other causes which I might enumerate, explain the frequency with which the 
os uteri deviates in colour, volume, and secretion, from the strictly healthy 
standard. In fact, we may compare the upper part of the vagina to the fauces, 
which is seldom found perfectly healthy in any subject who may be examined. 
Some of the indurations and enlargements of the os and cervix uteri appear to 

260 Progress of the Medical Sciences. [July 

resemble enlarged tonsils, and like them to increase in size without any amount 
of active inflammation. , 

The granulations which are sometimes found surrounding the os uteri — which 
may secrete mucus or pus abundantly, and which may bleed on being roughly 
handled — are, I have no doubt, the result of inflammation ; but they resemble the 
granular state of the conjunctiva, rather than the granulations of a true ulcer, 
the granular os uteri offering no edges or signs of solution of continuity by 
which we might satisfactorily declare it to be an ulcer. The granular os uteri 
would be a more correct designation in such cases than " ulceration" of the os 
uteri. Some of the so-called ulcerations appear to be nothing more than patches 
of thickened epithelium or portions of the os and cervix, from which the epithe- 
lium has been removed by acrid or irritating secretions. We can imitate this 
condition of the parts by the slight application of the nitrate of silver — sufficient 
to affect the epithelial covering, but not sufficient to injure the mucous mem- 
brane beneath. 

It appears to me that we can neither receive the' existence of excoriation or 
abrasion, of granulation or fungous growths, the secretion of pus or muco-puru- 
lent matter, as affording undeniable evidence of the existence of " ulceration" 
of the os and cervix uteri. We must try ulceration in this part of the body by 
the same tests which we apply to ulcers in other parts of the economy. We 
must look for a solution of continuity, with a secreting surface, separated from 
the healthy structures, having defined edges, everted or inverted, for an ulcer, 
In fact, in the common pathological meaning of the term, we find ulcers having 
these characters in the air-passages, mouth, stomach, intestines, bladder, and 
other mucous surfaces. There is no mistaking the characters of an intestinal 
ulcer after dysentery, and there ought to be no mistake about an ulcer of the 
uterus. Indeed, in the corroding ulcer of the uterus we unfortunately see that 
this organ is but too capable of taking on all the qualities of ulceration, in a 
degree only equalled by its extraordinary vitality, the organ being scooped out, 
or eaten away in a comparatively short space of time. Cases are also met with 
in which the os uteri has been destroyed by the sloughing ulceration and loss 
of structure, sometimes following the application of the more powerful caustic 
agents. We are, however, called upon by the unlimited believers in uterine 
ulceration to admit that ulcerative disease may exist for years in its common 
form without any perforation, excoriation, serious loss of substance, or altered 
configuration. Whether we test the so-called ulceration of the uterus by ulcer- 
ation occurring in other mucous surfaces, or in the uterus itself under un- 
doubtedly ulcerative disease, the distinctive characteristics are wanting in the 
great majority of cases ; and they certainly are not found, unless I am most 
egregiously mistaken in the enormous proportion of 222 cases of ulceration to 
300 cases of promiscuous uterine disease. 

In all that I have said, I do not wish it to be supposed that I question the 
frequency of irritation, chronic inflammation, and subacute inflammation in 
connection with leucorrhoea. Recent writers would, however, treat leucorrhoea 
merely and solely as a symptom, not as an independent disorder. But I am 
well assured that it is often the disease itself, or at least all of it that we can 
appreciate ; and that the irritable or inflammatory condition is excited second- 
arily and mainly by the morbid leucorrhoeal secretion. Some change in the 
innervation or nutrition of the organ occurs, or it sympathizes with a malady 
in some remote organ, and the secretions are consequently depraved. These 
depraved secretions irritate the surfaces with which they come in contact, and 
produce the visible signs of irritation or inflammatory action. We see these 
discharges sometimes inflame and excoriate even the external integument, but 
we should never dream of saying that the inflamed condition of the skin was 
the essential part of the disorder. The same observation applies to the uterus. 
Thus it is not pathological nor useful always to consider leucorrhoea as a mere 
symptom; and the old plan of astringent injections, though sometimes mis- 
chievous, cannot quite be dispensed with ; for in some, even profuse leucorrhoeas, 
an astringent injection by arresting the utero-vaginal discharges, does more 
than any other plan to soothe inflammatory conditions, or rather to suspend 
their causes. 

1850.] Midwifery. 261 

Notwithstanding the use of the speculum — notwithstanding the use of lamps 
and glasses, there is often considerable difficulty in ascertaining the precise 
condition of the cavity of the uterine cervix, engorged as it is, and deep in colour 
from irritation or other disease, and from the interruption to the circulation in 
the uterine organs, which is almost necessarily dependent on the introduction 
and expansion of the speculum within the vagina. But in the dead subject no 
such difficulties exist ; and it might certainly be expected, since leucorrhoea is 
a malady so very common, that uterine ulceration would be frequently revealed 
by post-mortem examinations. The only place in which, so far as I am aware, 
post-mortem examinations have been conducted in considerable numbers, with 
special reference to the determination of the frequency or infrequency of ulcer- 
ation of the os and cervix uteri, is at St. George's Hospital. For several years 
past, the condition of the uterus has been examined with great minuteness and 
accuracy in the dead subject at this hospital. 

Mr. Pollock, one of the lecturers on anatomy at St. George's Hospital, informs 
me that for more than three years, during which he was curator to the hospital 
museum, he examined the uterus internally and externally in all the subjects 
in the dead-house. During this time upwards of one hundred women died in 
the hospital annually. In each case the uterus was laid open and carefully 
inspected. Mr. Pollock only detected actual and unmistakeable ulceration in 
four cases. Of these, three were scrofulous subjects, and scrofulous ulceration 
existed in other parts of the body ; and in one of them the ulceration involved 
the vagina extensively as well as the os uteri. 

Mr. Gray, who succeeded Mr. Pollock as curator, informs me that during his 
curatorship he examined the bodies of one hundred and eighty women, who 
had died of all diseases in St. George's Hospital, with a distinct view to ascer- 
tain the proportion of cases in which ulceration of the uterus existed. These 
examinations were also conducted with great care and minuteness. Out of the 
one hundred and eighty subjects, distinct ulceration of the os and cervix was 
found in only three instances. Slight abrasions, discolourations, and granula-